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This section can be signed only by the patient, parent, or guardian. If the patient is mentally or physically capable during your course of treatment, their signature must appear below. The witness signature may be completed by family members, facility staff, EMS crews, or anyone who witnesses the patient signature. Note: patient unavailability after arriving at the destination is not a legitimate reason for incapacity to sign. If the patient signs with an “X” or other mark, a witness should sign below X Gladys Johnson 10/15/11 X_____________________________________ Patient Signature or Mark Date Witness Signature Date SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing. NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
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On the line below, explain the circumstances that make it impractical for the patient to sign: “ unable to sign due to significant contractures of hand, ” “ unable to sign due to full spinal immobilization, ” “ unable to sign due to altered level of consciousness, ” unable to sign due to immobilization of wrist due to IV site placement, ” etc This section can only be signed by one of the individuals listed below, and can utilized only when the reason on the line above is supported by your clinical documentation supports the reason indicated on the line above. This section is most often utilized for family member (spouse, adult son or daughter, other family member, in-home caregiver, or staff of sending facility . The form explains that their signature is not an acceptance of financial responsibility for the services rendered. Authorized representatives include only the following individuals: Patient ’ s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient ’ s treatment or exercise other responsibility for the patient ’ s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient X Susan Smith, RN 10/15/11 Sue Smith, RN 21000 Facility Drive OR X Mike Jones, Son 10/15/11 Mike Jones, 19191 Homestead Lane Representative Signature Date Printed Name and Address of Representative SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
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SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and (2) No authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service. A. Ambulance Crew Member Statement ( must be completed by crew member at time of transport ) This section is signed by an EMS crew member ONLY when the patient is unable to sign due to the reason indicated on the line below (and the reason is supported by EMS clinical documentation,) and none of the people in section two above are available or willing to sign . Both the A and B components of this section must be signed. This will be most often used when the patient arrives at a facility, can not sign due to physical or mental incapacity (as described in EMS clinical documentation,) and there is no family, guardian, or other patient representative available to sign. On the line below, explain the circumstances that make it impractical for the patient to sign: “ unable to sign due to significant contractures of hand,” “unable to sign due to full spinal immobilization,” “unable to sign due to altered level of consciousness,” unable to sign due to immobilization of wrist due to IV site placement,” etc Name and Location of Receiving Facility: _ Happy Healing Hospital, 99 Mile Rd, Clinton Township Time at Receiving Facility: 14:35 X Kolby Miller 10/15/11 Kolby Miller, EMT-P Signature of Crewmember Date Printed Name and Title of Crewmember Receiving Facility Representative Signature The patient named on this form was received by this facility at the date and time indicated above. My signature is not an acceptance of financial responsibility for the services rendered to this patient. X Scott Monk, RN 10/15/11 Scott Monk, RN Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
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Thanks for your attention, and your anticipated effort! If you have any questions, please see Jodi , Scott, or a supervisor….we will make sure you get the answers you need. Listen to one more audio clip…..
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Thanks, Kolby