Medical Record Request - Alice Rouge

[Alice Rouge]

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REQUEST FOR RELEASE OF MEDICAL RECORDS

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1. Patient Information

1.1 Patient Name: Alice Rouge

1.2 Incident Date: 01/01/2024

2. Requesting Parties Information

2.1 Name of Requestor: Alice Rouge

2.2 Phone: 888-2422

2.3 Email Address: [email protected]

3. Relationship to Patient

[X] Patient
[-] Parent of Minor
[-] Parent/Legal Guardian of Disabled Adult
[-] Power of Attorney
[-] Beneficiary
[-] Legal Guardian
[-] Executor of Estate
[-] Patient Authorized Representative
[-] Representing Attorney
[-] Law Enforcement
[-] Spouse/Significant Other

4. Declaration & Acknowledgement

By submitting this form, I hereby request that the RCFD release the patient’s health information maintained by RCFD.

Re-Disclosure: I understand that the information used or disclosed may be subject to re-disclosure by the
person, agent, class of persons or facilities receiving it, and may no longer be protected by state and federal
confidentiality laws.

Signature: arouge
Date: 01/02/2024

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

[David Raines]

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MEDICAL RECORD REQUEST RESPONSE

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Dear Ms. Rouge,

Your request has been approved and your medical record file has been released. You may view the document(s) in a PDF format below. (( Sent as an email ))

Spoiler: show

WALLACE MUNDELL Fire Chief

10 Palomino Way Palomino Creek, SA

PATIENT CARE REPORT

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RUN INFORMATION

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DATE OF DISPATCH:
01/JAN/24

INCIDENT TYPE:
[X] Trauma
[] Medical
[] Combination

PRIORITY LEVEL:
[] Priority 1
[X] Priority 2
[] Priority 3
[] Priority 5
[] Priority 4

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PATIENT INFORMATION

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PATIENT NAME: Alice Rouge

PATIENT AGE:
[] Infant (<1yrs)
[] Child (1 year to Puberty)
[X] Adult (Puberty to 65 years)
[] Geriatric (65>yrs)

PATIENT SEX:
[] Male
[X] Female

PATIENT RACE:
[] Caucasian
[X] Black
[] Asian
[] American Indian/Alaskan Native
[] Hispanic
[] Pacific Islander/Native Hawaiian
[] Other

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PATIENT ASSESSMENT

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CONSCIOUSNESS LEVEL:
[X] Alert
[] Verbal
[] Painful
[] Unresponsive

AIRWAY:
[X] Unobstructed
[] Obstructed

BREATHING:
[X] Adequate
[] Inadequate
[] None

CIRCULATION:
[X] Adequate
[] Inadequate
[] None

IN LESS THAN TEN WORDS EXPLAIN THE MAIN COMPLAINT
ECCHYMOSIS LEFT BUCCAL/MALAR FAT PAD W/O BLEEDING.

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PATIENT TREATMENT

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IV ESTABLISHED:
[] Yes
[X] No

ADVANCED AIRWAY ESTABLISHED:
[] Yes
[X] No

MEDICATION ADMINISTERED:
[X] Yes
[] No

LIST ALL MEDICATIONS GIVEN:
ICE PACK.

BRIEFLY EXPLAIN THE TREATMENT ADMINISTERED:
BFT LEFT BUCCAL/MALAR FAT PAD, ECCHYMOSIS (W/O BLEEDING), ICE PACK FOR PAIN, FULLY ALERT & VERBAL, GCS 15, A&OX4.

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PATIENT DISPOSITION

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DISPOSITION:
[X] Released
[] Transport
[] Deceased

TRANSPORT LEVEL:
[] Emergent
[] Non-Emergent

FACILITY:
[] Crippen Memorial Hospital
[] Fort Carson Medical Center
[] Las Venturas Memorial Hospital
[] San Fierro Medical Center
[] All Saints General Hospital
[] County General Hospital

Signed,

Audrey McLeod, Fire Chief
Red County Fire Department