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.