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FAX To: (509)574-2159 EMS REQUEST FOR RECORDS

This form must be used, to request any local Yakima County Prehospital QI/QA Committee to review an incident. Please note that all of the data elements need to be completed or we may not be able to honor your request. When sending in requests please attach MIR(s), and/or patient outcome report from hospital. If it is not possible to attach a copy, then please supply name of person, phone number and email address to obtain report(s) and any forms that are needed to complete the request.

PATIENT INFORMATION

|NAME (FIRST, MIDDLE, LAST) |SEX |DATE OF BIRTH |SOCIAL SECURITY NUMBER |

|PERMANENT ADDRESS (STREET & APARTMENT NUMBER) |REASON FOR REQUEST (i.e. patient care issue, transport decision concern, etc.): |

| | |

|PERMANENT ADDRESS (CITY, STATE & ZIP) | |

|PHONE NUMBER (INCLUDE AREA CODE) |AGE | |

|( ) - | | |

|OCCUPATION | |

|MOTHERS NAME (IF PATIENT AGE IS LESS THAN 18) |FATHERS NAME (IF PATIENT AGE IS LESS THAN 18) |

|MOTHERS ADDRESS (STREET) |SAME AS ABOVE |FATHERS ADDRESS (STREET) |SAME AS ABOVE |

|MOTHERS ADDRESS (CITY, STATE & ZIP) |FATHERS ADDRESS (CITY, STATE & ZIP) |

INCIDENT INFORMATION

|INCIDENT LOCATION (STREET & APARTMENT NUMBER) |INCIDENT DATE |TIME OF TRANSPORT | |

|INCIDENT LOCATION (CITY, STATE & ZIP) |TYPE OF INCIDENT |TYPE OF ILLNESS/INJURY | |

|FIRE DEPARTMENT/DISTRICT |UNIT NUMBER |MIR NUMBER |MIR Attached? |

|TRANSPORTING AMBULANCE |UNIT NUMBER |MIR NUMBER |MIR Attached? |

|HOSPITAL TRANSPORTED TO |CONTACT INFORMATION |Medical Record Attached? |

What type of information are you requesting?

|Type of QI/QA |Hospital |Ambulance/Fire |Dispatch |

YC Prehospital QI/QA Call Review |In-House QI/QA Call Review |Complete Medical Record |Summary Report |Patient Disposition |Emergency Room Report |Pictures |X-Rays |Patient Care Report or Medical Incident Report |SunCom 911/Dispatch Tape | | | | | | | | | | | | |

Signature of Person Requesting Print Name Here Date

Signature of EMS Office Representative Print Name Here Date

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