Request for Patient Follow-Up

Request for Patient Follow-Up

Submit this request to obtain patient information from the receiving facility
***EMIHS staff will forward any correspondence regarding COVID positive patient interactions to all impacted responders***
Incident Number*
Incident Date*

MonthDayYear
Your Name*
Your Email*
Transport Unit*
Type NA as needed
Receiving Facility*
Notes / Additional Information*
DO NOT ENTER ANY PROTECTED HEALTH INFORMATION
Office Use Only
Staff
Status
Date Closed

MonthDayYear
Should be Empty: