Patient Enrollment by Physician

If you are a licensed Colorado physician with a written MOU on file with UPRHSD and would like to order a patient visit with the UPRHSD Community Paramedicine Program, please fill out the form below.

NOTES: Your submission of this order form must be followed up by a phone call to the Appointment PSAP Center. This form must be fully completed and submitted for each POP visit desired for every patient. You will have the opportunity to resubmit the form with most patient information retained after each submission. Instructions will be provided after submission.

This form may take several days to be processed and is not designed to manage emergency situations.

All information submitted via this form is encrypted and handled in strict accordance with HIPAA law.

Paramedic Advanced Care Team - Physicians Prescription Order For Service
Medical Information
Patient Information
Patient DOB
Assessment & Treatment

Physician Information
Visit Date and Time