Medical Incident Report Mir Order Form
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1Office of Community Health Systems
MEDICAL INCIDENT REPORT (MIR) ORDER FORM
Make Check or Money Order Payable To:
DOH, Emergency Medical Services
PO Box 1099
Olympia WA 98507-1099
REQUESTOR’S NAME
DATE
TELEPHONE NUMBER
AGENCY/FACILTY NAME
AGENCY/FACILITY NUMBER
FEDERAL ID NUMBER (IF APPLICABLE)
MAILING/SHIPPING ADDRESS
CITY
STATE
ZIP CODE
ITEM
PRICE
INDICATE QUANTITY
MIR Forms
2 Pads (50 Forms)
$13.64
8 Pads (200 Forms)
$34.14
1 Case (36 Pads) Indicate number of cases desired
$132.41
MIR form Amount
Supplemental MIR Forms
1 Pack (25 Forms)
$11.00
1 Case (800 Forms)
$64.25
Supplemental MIR form Amount
SUBTOTAL
Add local sales tax amount or leave blank and attach exemption documentation.
TOTAL AMOUNT
Questions? Contact us at (360) 236-2800.
DOH 530-108 April 2010
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Please separate before mailing - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Medical Incident Report (MIR) Order
For DOH Use Only
Name________________________________________________________________________________________________
Amount Paid____________________________________________ Date Filled_____________________________________
By Whom_____________________________________________________________________________________________
THIS FORM MAY NOT BE DUPLICATED
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