Region 1 South Voluntary Transportation System Request
Illinois Patient Transport (IPT), a division of Advanced Medical Transport (AMT), through contract with State of Illinois Department of Human Services, will provide transportation services to voluntary patients in Region 1 South to and from specific facilities identified in the Region 1 South Crisis Care System Policies and Procedures.
Requesting a Transport
Once a patient is deemed eligible for transportation by the Eligibility Disposition and Assessment Evaluator, call AMT's Communication Center, complete the front and back of the Region 1 South Voluntary Transportation System request form. Fax the transport request form, front and back to AMT using the fax number at the top of the form.
Request Form (attached)
The top of the request form provides the phone and fax number to AMT.
The name and a contact number to reach the Eligibility Determination and Assessment Evaluator will be provided.
Identify by checking the correct box the type of facility the patient will transport to; 1) CHIPS, Community Hospital Inpatient Psychiatric Services, 2) DASA, Substance Abuse Residential Crisis Stabilization, 3) Mental Health Crisis Residential, or 4) John J Madden Mental Health Center.
Clearly provide the authorization number for the transport as well as the date of service.
Complete the section on the front of the form marked "Patient Information" leaving no blanks. In rare circumstances where a social security number is not available clearly note "none available".
Complete the section marked "Pre-transport Risk Assessment". This tool assures each patient is transported in the safest manner possible. Please be prepared to discuss this section with the dispatcher to assure IPT is aware of the condition and demeanor of the patient.
Pre-transport Risk Assessment:
- 1. Do physical limitations prohibit transport by car; ambulatory, weight, or other?
If the patient cannot transport by car and ambulance may be sent.
- Is the patient a juvenile? (IPT does not transport minors)
- Are there identified complicating medical conditions with potential for difficulty en route?
Medical conditions may require an ambulance transport. Potential for seizures will be a concern.
- Is there potential for drug or alcohol withdrawal en route?
Determine the likelihood the patient may experience withdrawal and the distance of the transport, patients likely to experience withdrawal may require and ambulance.
- Is there a history of violence or assaultive behavior?
Please share any information regarding the patient's behavior just prior to admission (possible domestic violence) as well as the behavior exhibited in your facility.
- Has the patient been search for contraband?
For the patient's safety and the technician, patients must be searched for weapons.
- Was there use of PRN medication for agitation with this ER admission?
Medication used to calm is acceptable (Ativan, Xanax), medication used to sedate or control behavior are not appropriate for a car transport and may require an ambulance.
- Is the patient aware of the voluntary transport and the location of treatment services?
The patient will likely be more cooperative when included in the treatment plan.
- Has the patient been accepted at the receiving facility?
We want to make sure we will not arrive with the patient at the destination to find there is no treatment available to the patient.
On the back of the form, fill out the details regarding your facility as well as the destination facility. A contact name and number will be necessary.
At this point, provide the form to the patient with the back in view. Along with the destination, the patient will have two sentences to read and a signature line with date. The patient acknowledges the transport is directly to the facility. By signing, the patient is providing a psychological commitment more than a legal one. This is designed to reduce the chance an individual may change their mind en route or request an alternative destination.
Upon arrival, the transport technician will obtain an update on any changes in the patient's condition and demeanor. Provide the form to the technician for review. Complete the box under the patient's signature marked Transferring Facility Sign Off. The technician will take the request form with him.
The technician will escort the patient to the vehicle. The final box on the form will be completed upon arrival at the destination facility.