EMC Form

Patient Information

Date of Birth(Required)

Phone(Required)

Accident Date(Required)

Date of First Visit(Required)

Please specify other type of accident

Provider/Clinic Information

Provider Name(Required)

License #(Required)

Clinic Name(Required)

Provider Phone(Required)

Provider Email(Required)

Chief Complaint

Describe patient's primary symptoms related to accident(Required)

Clinical Findings

Pain Location

Please specify other symptoms

Objective Findings

Diagnostic Studies (if applicable)

Summary of Results

Emergency Medical Condition (EMC) Determination

Under Florida law (F.S. § 627.732(4)(a)), an Emergency Medical Condition (EMC) is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:

• Serious jeopardy to bodily function or health
• Serious dysfunction of any bodily organ or part
• Serious disfigurement

Medical Necessity & Treatment Plan

Initial clinical impression and medical necessity for care(Required)

Please specify other treatment

Frequency

Duration

Provider Certification

I certify that the information above is true and accurate to the best of my knowledge and is based on my professional examination.

Provider Signature(Required)

Type your full name to serve as electronic signature

Printed Name(Required)

Date(Required)

Office Use

Office Notes / Additional Observations

Emergency Medical Condition (EMC) Determination Form