MH TRANSPORTS - CONSTABLES OFFICE

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CONSTABLES OFFICE

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BEHAVIORAL HEALTH TRANSPORT INVOICE

PLEASE COMPLETE

* Indicates required field

PRIMARY CONSTABLE NAME *

SECONDARY CONSTABLE / RIDE ALONG *

Constable Name (IF Not in list above) *

DATE OF SERVICE *

HOSPITAL *

DESTINATION FACILITY *

911INET INCIDENT # *

SUBJECT NAME *

GENDER *

MALE FEMALE

IS THE SUBJECT A MINOR (UNDER 18) *

YES NO

COMMITMENT *

201 302 OTHER

TURNPIKE UTILIZATION *

YES NO

EMAIL TURNPIKE RECEIPTS TO: MCO.INVOICING@GMAIL.COM

INVOICE LIFETEAM EMS *

YES NO

TOTAL TURNPIKE FEES *

Time of Arrival at Hospital *

Time of Arrival at Receiving Facility *

Time you CLEARED the Receiving Facility *

Mileage at PICKUP Facility (Beginning) *

Mileage at DROPOFF Facility (Ending) *

ANY ISSUES *

DOCUMENT ANY ISSUES DURING TRANSPORT, INCLUDING TRAFFIC DELAYS OR DELAYS AT FACILITIES

Submit

We Would Love to Hear From You Soon!

Hours

M-F: 8am-4pm

Telephone

717-688-6262

Email

info@constablesoffice.us