EmailMe Form - Rescue 1 LLC Trip Ticket

Rescue 1 Paramedic Services LLC
221 W. Madison Ave
Chrisman, IL 61924

Run Number:
Transport Date/ Time of Call: *
MM / DD / YYYY HH : MM AM/PM
Unit#: *
Clear:
HH : MM AM/PM
Total Wait Time (In hours and minutes):
Billable Miles: *

Loaded

Unloaded (VA Not Req.)
Transport Type: *
Stay and Wait
One Way
Standby
Pickup Location: *
Destination: *
Other Location not listed:

Pickup Location:

Destination:
Patient Name: *
First Middle Last
Patient Date of Birth:
MM / DD / YYYY
Patient Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Ticket Information *

Last 4 SSN:

Approval#

Reason for Transport:
Additional Notes:
Bill To:
Employee:
Employee Email:
Care Transfered to:
Clear

Loaded
Unloaded (VA Not Req.)

Pickup Location:
Destination:

217.269.3911 Dispatch www.rescue1paramedics.com 217.269.2242 Fax