Coastal Spine And Pain Center - Notice Of Emergency Medical Condition

Download a blank fillable Coastal Spine And Pain Center - Notice Of Emergency Medical Condition in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Coastal Spine And Pain Center - Notice Of Emergency Medical Condition with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

NOTICE OF EMERGENCY MEDICAL CONDITION
The undersigned licensed medical provider, hereby affirms:
1. The below injured patient, has in the opinion of this medical provider, suffered an
Emergency Medical Condition, as a result of the patient’s injuries sustained in an
automobile accident that occurred on _______________________ (fill in date of accident).
2. The basis for the finding of an Emergency Medical Condition is that the patient has
sustained acute symptoms of sufficient severity, which may include severe pain, such that the
absence of immediate medical attention could reasonably be expected to result in any of the
following: a) serious jeopardy to patient health; b) serious impairment to bodily functions; or
c) serious dysfunction of a bodily organ or part.
I hereby attest that I am a physician licensed under chapter 458 or chapter 459, a dentist licensed
under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced
registered nurse practitioner licensed under chapter 464, and that the above facts are true and
correct.
_________________________
___________________________
____________
Name (PRINT or TYPE)
Signature of medical provider
Date
The undersigned injured person or legal guardian of such person affirms:
1. The symptoms I reported to the medical provider are true and accurate
2. I understand the medical provider has determined I sustained an Emergency Medical
Condition as a result of the injuries I suffered in the care accident.
3. The medical provider has explained to my satisfaction the need for future medical attention
and the harmful consequences to my health which may occur if I do not receive future
treatment.
Injured patient receiving this diagnosis or legal guardian of said injured patient:
______________________
___________________________________
____________
Name (PRINT or TYPE)
Signature of injured patient/guardian
Date

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Report Of Medical History - Gable Health And Counseling Center/department Of Sports Medicine Report Of Medical History - Gable Health And Counseling Center/department Of Sports Medicine Medical
School Medication Authorization Form; Self-administration Of Emergency Medications Template School Medication Authorization Form; Self-administration Of Emergency Medications Template Business
Intermediate/99 Recertification Form 2010 - The National Registry Of Emergency Medical Technicians Intermediate/99 Recertification Form 2010 - The National Registry Of Emergency Medical Technicians Medical
Form Ime-5 - Claimant's Notice Of Independent Medical Examination Form Ime-5 - Claimant's Notice Of Independent Medical Examination Legal
Sec Form 1-n - Form And Amendments For Notice Of Registration As A National Securities Sec Form 1-n - Form And Amendments For Notice Of Registration As A National Securities Legal
Employer's First Report And Employee's Notice Of Injury Or Occupational Illness Template Employer's First Report And Employee's Notice Of Injury Or Occupational Illness Template Legal
Medical History And Pain Assessment Form Medical History And Pain Assessment Form Medical
Conditional Partial Waiver Of Liens And Claims, And Affidavit Of Payment - Jgj Conditional Waiver Conditional Partial Waiver Of Liens And Claims, And Affidavit Of Payment - Jgj Conditional Waiver Legal
Notice Of Eligibility And Rights & Responsibilities (family And Medical Leave Act) - Colorado State University Notice Of Eligibility And Rights & Responsibilities (family And Medical Leave Act) - Colorado State University Business
Medical Rescue Certification Inspection Form (new Mexico Dept. Of Health, Emergency Medical Systems Bureau) Medical Rescue Certification Inspection Form (new Mexico Dept. Of Health, Emergency Medical Systems Bureau) Business

Related Categories

Parent category: Business
Download
Go