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CONTACTED BY A CONSTABLE
CONTACT
WHAT IS A CONSTABLE
BEHAVIORAL HEALTH TRANSPORT INVOICE
PLEASE COMPLETE
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Indicates required field
PRIMARY CONSTABLE NAME
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PICK ONE
KARL SCHELL
TEDDY GROTHE
BRIAN GABEL
KURT HOUPT
DERON KOPPENHAVER
JEFF SHANK
CHRISTOPHER TOPPER
JOHN WEISER
TERRY WHITE
STEPHEN BEANS
SHAUN SPONAGLE
SECONDARY CONSTABLE / RIDE ALONG
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NONE
STEPHEN BEANS
KARL SCHELL
KURT HOUPT
TEDDY GROTHE
TED GROTHE (TEDDY DAD)
DERON KOPPENHAVER
DARLA SHANK
JEFF SHANK
CHRISTOPHER TOPPER
JOHN WEISER
BRIAN GABEL
TERRY WHITE
DARIA BASS
ELIZABETH TOPPER
DEKA TOPPER
ANDREW MESSINGER
CHRISTINA SPONAGLE
TINA SPONAGLE
DENNIS RISHEL
Constable Name (IF Not in list above)
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DATE OF SERVICE
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HOSPITAL
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PSH- HOLY SPIRIT
UPMC- HANOVER
GETTYSBURG
UPMC- HARRISBURG
UPMC- WEST SHORE
YORK
UPMC- YORK MEMORIAL
PSH- HAMPDEN MEDICAL CENTER
UPMC- CARLISLE
UPMC- OSTEO
UPMC- LITIZ
WELLSPAN-WAYNESBORO
UPMC-CARLISLE
DESTINATION FACILITY
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911INET INCIDENT #
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SUBJECT NAME
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GENDER
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MALE
FEMALE
IS THE SUBJECT A MINOR (UNDER 18)
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YES
NO
COMMITMENT
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201
302
OTHER
TURNPIKE UTILIZATION
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YES
NO
EMAIL TURNPIKE RECEIPTS TO: MCO.INVOICING@GMAIL.COM
INVOICE LIFETEAM EMS
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YES
NO
TOTAL TURNPIKE FEES
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Time of Arrival at Hospital
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Time of Arrival at Receiving Facility
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Time you CLEARED the Receiving Facility
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Mileage at PICKUP Facility (Beginning)
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Mileage at DROPOFF Facility (Ending)
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ANY ISSUES
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DOCUMENT ANY ISSUES DURING TRANSPORT, INCLUDING TRAFFIC DELAYS OR DELAYS AT FACILITIES
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