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.)
- 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.)
- DNR Forms (from Maine EMS) (Go to the bottom of this page link for all DNR Forms.)
- 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.)
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.)
- Monthly Equipment Checklist (Click here for 7-1-08 Changes)(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.)
- Mileage Chart (But odometer reading always takes precedence - routes may vary.)
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.)
- 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'.)
