Center Street, Westminster, MD 21157 PHONE: (410) 876-4813 FAX: (410) 876-4957-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1 - Patient Personal Information. Fill in the patient's Last Name, First Name, Height, Weight, Date of Birth, and complete address including City/State/Zip. Ensure accuracy for proper identification.
3. Continue to Section 2 - Facility Discharges and Transfers Information. Enter the sending and receiving facility details including addresses and contact information. Specify the Date & Time Requested for transport.
4. In Section 3 - Medical Diagnosis and Condition, clearly describe the underlying medical diagnosis and condition requiring transport. Avoid using ICD or DSM codes; instead, provide a detailed explanation of symptoms.
5. Choose one mode of transportation in Section 4. Indicate if the patient is ambulatory or requires a wheelchair or ambulance service. Check all applicable conditions such as ramps or steps.
6. Finally, complete Section 5 - Provider Certification by having an authorized signee certify the form with their signature, printed name, date signed, and contact information.

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