Patient Signature Form

Section 2 - EMERGENCY OPERATIONS

PURPOSE:

To establish a procedure for obtaining a “patient signature” on all transports performed by the Maitland Fire Rescue Department to meet the requirements for release of information and insurance filing required by Medicare and other insurance companies. Also establishes the necessity of obtaining signatures on patients that refuse transport and/or treatment. MFD reserves the right to obtain unpaid balances for services through collections service payment. Any cost incurred shall be the responsibility of the party billed.

PROCEDURE:

It is the responsibility of crew members to obtain a signature from each patient (or guardian) transported and to obtain a signature on patients that refuse transport and/or treatment.

All Transports:

• Each patient transported will be asked to sign the Maitland Fire Rescue Department Patient Signature Form or the electronic Patient Signature Form within ePCR which gives the City of Maitland permission to bill the patients insurance company, to release any information necessary to said insurance company and guarantee the patient’s payment if insurance is denied.
• If the patient is unable to sign his/her full name, an “X” will be accepted, but must be witnessed by another adult and/or crewmember.
• If the patient is a minor, the crew will obtain the signature of the minor’s parent and/or guardian on the release form. If no parent or guardian is present, contact parent or guardian via phone and advise of situation (stable/no need for transport/transport to approved facility) have the paper or electronic form signed/witnessed.
• If the patient is unable to sign, a spouse or other immediate (adult) family member may sign for the patient on the Patient Signature Form hardcopy or electronic Patient Signature Form within the ePCR. Document why the patient was unable to sign, and the relationship of the person that signed for them.
• If the patient is unable to sign and no other adult is present to sign for the patient, a reason must be listed on the release form as to why the patient could not sign. (Examples – Unresponsive, Combative, Patient Refused)
• Place patient’s name, Maitland incident number, and date of call on all Patient Signature Forms (hardcopy).
• Digitally upload hardcopy of Pt signature form into ePCR.

All Refusals:

• All patients encountered with injuries and/or conditions that would warrant the transport of the patient to the hospital for care, but who refuse transport should be asked to sign the Patient Release form.
• Current procedures for documentation of auto accidents and other calls with no injuries will be followed