MH TRANSPORTS

BEHAVIORAL HEALTH TRANSPORT INVOICE

* Indicates required field

PRIMARY CONSTABLE NAME *

SECONDARY CONSTABLE *

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

TOTAL TURNPIKE FEES *

Mileage at PICKUP Facility (Beginning) *

Mileage at DROPOFF Facility (Ending) *

Time of Arrival at Hospital *

Time of Arrival at Receiving Facility *

Time you CLEARED the Receiving Facility *

ANY ISSUES *

Submit