Discharge Intake Form
Facility Information
Facility Name
*
Point of Contact (POC)
*
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Member Information
Member's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Height
*
Weight (Lbs)
Member ID
*
Insurance Type
*
Please Select
CenCal Health
Gold Coast Healthplan
Private
Transportation Mode
*
Please Select
Wheelchair
Extra Large Wheelchair
Extended Wheelchair
Gurney
Ambulatory - Regular Vehicle
Communicable Disease
*
Please Select
Yes - Isolation
Yes
No
Service Level
*
Please Select
Basic Life Support
Advanced Life Support
Additional Mobility Assists
*
Please Select
Walker
Cane
Curb to Curb Assistance
Door to Door Assistance
Does not need Assistance
Does member need to be provided with oxygen?
*
Yes
No
Is member on dialysis?
*
Yes
No
Does member use a wheelchair?
*
Yes
No
Does member need a wheelchair provided for them?
*
Yes
No
Comments:
Transport Information
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Service
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Attendant
*
Please Select
Yes
No
Attendant's Name
*
Relationship
*
Attendant's Phone Number
*
Format: (000) 000-0000.
Pick-Up Information
Type of Location
*
Please Select
Hospital
Skilled Nursing Facility
Long-term Care
Desired Time
*
Hour Minutes
AM
PM
AM/PM Option
Pick-Up Address
*
Street Address
City
State / Province
Postal / Zip Code
Wing
*
N/A if not applicable
Room
*
Bed
*
N/A if not applicable
R.N Stations Phone Number
*
Format: (000) 000-0000.
Extension
*
N/A if not applicable
Drop-Off Information
Type of Location
*
Please Select
Hospital
Skilled Nursing Facility
Long-term Care
Home
Shelter
Drop-Off Address
*
Street Address
City
State / Province
Postal / Zip Code
How many stairs at location?
*
N/A if not applicable
Are there any obstructions?
*
Please Select
Yes
No
Anything blocking the entrance
Who will receive member?
*
Please Select
Self
Spouse
Caregiver
Drop-off point of contact (POI) #
*
Format: (000) 000-0000.
Comments
Acknowledgement and Disclaimer
You attest that the information provided is complete and accurate to the best of your knowledge. Please note that submitting this form does not guarantee transportation.
*
Ventura Transit System (VTS) is solely responsible for the transportation of the patient. VTS cannot assist a patient into a residence that does not comply with the Americans with Disabilities Act (ADA). If the patient is not received at the drop-off location or cannot be accommodated, they will be returned to the emergency room. Additionally, VTS can only transport personal belongings that can be carried on a lap or between the patient’s legs.
*
Submit
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