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Request Patient Disposition Report

  1. Ambulance Crew
  2. This form is only to be filled out by the lead paramedic that provided care to the patient.

    The attempt to use this service by anyone who was not the lead paramedic is a violation of the Health Insurance, Privacy and Accountability Act (HIPAA) and will result in punishment up to and including termination of employment.
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  4. This field is not part of the form submission.