Ada County Paramedics Patient Referral

Community Paramedic Referral Form for EMS, Police and Fire

Community Paramedic Fax (208) 287-5812
Communityparamedics@adacounty.id.gov

If you're an EMS system partner interested in referring a patient to the Ada County Community Paramedic Program, please fill out the form below and click “Submit.” If you have any questions, please don’t hesitate to contact the Ada County Community Paramedics at 208.287.2998 or 208.287.2993

This message is indented only for the use of the individual or entity to whom it is addressed. It may contain information that is privileged, confidential, and exempt from disclosure under law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the individual or entity, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone, (208) 287-2950, and return the original message to us at 370 N. Benjamin Ln, Boise ID 83704 via the U.S. Postal Service.

Today's Date

Your Name

Name is required

Your Email

Email is required

Client Information (Police and Fire departments only)

Client Last Name

Client last name is required

Client First Name

Client first name is required

Date of Birth

Age

Gender

Gender is required

Home Phone

Phone # is required

Street

City

State

Zip Code

Encounter Information

Date of Call

Call date is required

EM # (if applicable)

Agency

Agency is required

Is the client/patient aware you are making this referral?

Yes

This field is required

Please Indicate the Primary Reason for Referral

Inadequate Self Care

Resource Needs

Unsafe Environment

Other

Medication Reconciliation

Multiple/Frequent Calls

Fall Hazard

Description