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
2 digit month, 2 digit day, 4 digit year
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
2 digit month, 2 digit day, 4 digit year
Should be Empty: