Ambulance Provider Signature Log

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AMBULANCE PROVIDER SIGNATURE LOG
Company Name:___________________________
Employment
Employee Name, Full Signature, Credentials
Initials
Start Date
End Date
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Signature
____________________________________________________
Printed Name
____________________________________________________
 EMT  EMT-I  EMT-P Other:
(specify)
Please keep an official signature on file of all staff making entries in patients’ ambulance records and maintain the signatures in chronological
order according to the date of hire of the employee. Provide a copy of the appropriate page(s) when records are requested by the Funds for an
audit or a request for information to verify the authentication of ambulance records for reimbursement purposes.

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