A ready access to Forms often used by NorthStar Staff...
Patient Care/CQI Forms:
- 12 Lead Form (To be completed on all patients with 12 Lead EKG. Leave in EMS Room in 12 Lead Folder for Physician review.)
- Airway Form (To be completed on all patients with airway intervention. Fax completed form to Tom Doak at 897-6373.)
- Billing Authorization Form (for ALL patients going elsewhere (and thus not registered at FMH)) (To be completed for All patients transported to facilities OTHER THAN FMH and that do not originate at FMH (ie: for patients that need to be registered by Wade). Fax completed form to NorthStar Billing 235-2223.)
- Cardiac Monitor Strip Mounting Sheet (For, uh, mounting EKG strips. Leave in base files.)
- Consent for Transfer Form (Eff 6/2009)(Should have a COPY of one for every transfer out of FMH)
- CPAP Quality Data Form (To be completed for ALL CPAP use or attempted use. Fax to Tom Doak at 897-6373.)
- CPAP Hospital Data Collection Form (To be completed by hospital staff for all CPAP use. Leave with ER nurse. Ask that it be faxed to Tom Doak at 897-6373.)
- CQI Counseling Form (Completed when CQI issue need to be addressed.)
- CQI Review Form (What the CQI Committee is looking for on the run sheets.)
- DNR Forms (from Maine EMS) (Go to the bottom of this page link for all DNR Forms.)
- House Call Forms
- House Call Referral Form (For all the info on the resident - keep at base.)
- House Call Log Sheet (To record each and every visit - keep at base.)
- House Call Evaluation Form (What happened on the visit.)
- Home Safety Checklist (Just to make sure.)
- Notice of Exclusion from Medicare Benefits (NEMB) (for Medicare Patients) (To be completed for ALL Medicare patients when ambulance is not medically necessary. Fax completed form to NorthStar Billing 235-2223.)
- Physician Certification Statement (PCS) (for Medicare Patients) (To be completed for all Medicare patient transfers. Fax completed form to NorthStar Billing 235-2223.)
- PIFT Form (To be completed on all PIFT transfers. Fax completed form to Tom Doak at 897-6373.)
- Refusal Sign Off Form (For, naturally enough, patient refusals for transport.)
- Run Worksheet (To be left at receiving facility when e-run sheet is not available and for recording prelim info for the e-run sheet.)
- Transfer Order Form (1-09) (To get with every transfer out of FMH.)
Logs and Checklists:
- Daily Ambulance Equipment Checklist and Instructions (To be completed daily for all trucks.)
- Daily Vehicle Checklist (To be completed daily for all trucks.)
- Daily/Weekly Base Task List (Things that need to be done periodically at the Base.)
- Maine EMS Ambulance Equipment Inspection Form (What Maine EMS looks for.)
- Monthly Equipment Checklist (Last modified 1/16/10) (To be completed monthly for all trucks.)
- Out of Box Medication Log (7-1-08) Daily log to record OOB expiration dates.)
- Out of Box Medication Charge Slip (To be completed for Pharmacy whenever the OOB Drugs are used.)
- Drug Box Log (Daily log for Drug Box.)
- Drug Box Accountability Log (Inside the Drug Box/Usage report)
- Mileage Chart (But odometer reading always takes precedence - routes may vary.)
LifeLine
- LifeLine Flyer (A brochure/flyer to give out to the public)
HR and Related Forms
- PRN Bonus Worksheet (To be completed by PRNs that qualify every 6 weeks per schedule on Members Page. Turn in to Ops Mgr.)
- Preceptor/Student Rotation Summary Form (Preceptors and students must complete for every rotation. Give to Carol P.)
- Uniform Requisition Form (Use with NorthStar's "Company Store")
- Internal Application (Send to HR.)
- Earned Time Cash In Request (You must have signed up for this in the prior year.)
- Earned Time Transfer Request (You must have signed up for this in the prior year.)
- W-4 Form (For changing deductions.)
- Expense Reimbursement Form (Send to Manager for approval.)
- UMF Fitness Application (To get 'buff'.)
