Ambulance Services Claims Attachment


  Ambulance Services Claims Attachment
  
  

  
  
    
      
      
      
        125 City Avenue
        Miami
        FL
        33132-3111
      
      
        
          Jack
          J
          Jackson
        
        
        
      
    
  

  
  
    
    
      
      
        
        St. Holy Hills Hospital
        
          2345 Winter Blvd
          Miami
          FL
          33132-3111
        
      
    
  

  
  
    
      
        
        St. Holy Hills Hospital
        
          2345 Winter Blvd
          Miami
          FL
          33132-3111
        
      
    
  

  
  
    
      
    
  

  
    
      
        

           BODY WEIGHT AT TRANSPORT (COMPOSITE) 
          
            275 lb
          

        
      
      
        

          TRANSPORT DIRECTION
          
            Initial Trip
          

        
      
      
        

          RATIONALE FOR CHOICE OF DESTINATION 
          
            Patient was transported to nearest facility for care of symptoms, complaints or both.
          

        
      
      
        

          DISTANCE TRANSPORTED
          
            7 miles
          

        
      
      
        

          ORIGINATION SITE INFORMATION
          
            HOME
 1254 City Avenue
 Miami FL 33132-3111 
          

        
      
      
        

          DESTINATION SITE INFORMATION
          
             St. Holy Hills Hospital
 2345 Winter Blvd
 Miami FL 33132-3111 
          

        
      
      
        

          ADMITTED AT DESTINATION FACILITY ON TRANSFER
          
            Admitted