Patient Follow Up Form

Please use the form below to request patient follow-up information. The following information is required in the message in order to process your request:

Name of Transporting Agency
Name of Treating EMS Provider
Receiving Facility (Good Samaritan or Lutheran)
Date of Transport
Approximate Time of Arrival at the Facility

DO NOT include any patient identifying information! Follow-up information will be sent to your agency's EMS leader for forwarding to the treating provider. Please allow 7-10 days to process your request.

Information will only be released to individuals with direct patient involvement and the agency's Quality Improvement representative.