Fillable TRANSPORTATION FORM Transportation Form (Fort Sill Apache Tribe)

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TRANSPORTATION FORM Transportation Form (Fort Sill Apache Tribe)

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Revision2-03.03.2020
1-FSA-CHR
NAME: ________________________________________________ AGE: _______ D.O.B.: ______________________
MALE: _____ FEMALE: ____ TRIBAL AFFILIATION: _____________________ ENROLLMENT # _____________
ADDRESS: ___________________________________ CITY: _____________________ STATE: ____ ZIP: ________
Tribal Land: YES ___________NO___________ HOME/CELL/WORK PHONE #: ____________________________
CHART #: LIHS____________ AIHS_____________ OTHER_____________
Do you own and operate a vehicle? _______________ Do you have access to a vehicle? ______________
Do you have access to VA transports, Social Services or other mileage programs? If so please state which one.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
It is the policy of the Fort Sill Apache Tribe CHR Program to provide transportation to and from health care
facilities to members of Indians tribes who reside within the Fort Sill Apache Tribe CHR Program service area.
If transportation is to be provided, it shall be within the local community to/from an IHS or tribal hospital
or an IHS referral to outside clinic/hospital for routine, non-emergency problems, for a patient without
other means of transportation when necessary. The clients requesting transportation are encouraged to seek
family support first before calling the CHR Program. If in the opinion of the CHR Director, an individual may
have access to their own way for transportation, then requests for Fort Sill Apache Tribe CHR transportation
services can be denied. The client must give information pertaining to the need for transport in order for a decision
to be reached as to whether or not the client will be transported (including but not limited to):
a) Accurate date and time of appointment/s.
b) Place of appointment/s including correct physical address of facility.
c) Name of Doctor to be seen & phone number to medical facility.
d) Reason of appointment/s and the estimated length of time for scheduled appointment.
e) Procedures that must occur before or after the appointment including but limited too Labs, X-Rays, CT scan,
MRI, Fasting and Wound Care.
APPROVAL MUST BE OBTAINED BEFORE ANY TRANSPORT IS MADE!
Detailed explanation of why transportation is needed: ______________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Fort Sill Apache Tribe
43187 US HWY 281, Apache, OK 73006
Phone 580/588-2298 Fax: 580/588-3133
CHR Transportation Application
No
No
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2-FSA-CHR
MEDICATION LOG
PLEASE LIST ALL (PRESCRIBED AND OVER THE COUNTER) MEDICATIONS
CURRENTLY BEING USED.
List all Allergies: __________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List all Medical Conditions: ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Name of Medication
Dosage
Frequency
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
NAME
RELATION
PHONE NUMBER
1.
2.
3.
4.
5.
Revision2-03.03.2020
3-FSA-CHR
____ COMPLETED/SIGNED APPLICATION
____ COPY OF CDIB AND PROOF OF RESIDENCE
____ LIST OF CURRENT MEDICATION TAKEN AND 3 EMERGENCY CONTACTS
____ POLICY AND PROCEDURES / SIGNED WAIVER
The above and enclosed information is true to the best of my knowledge.
______________________________________ ____________________
Applicant and/or Guardian Signature Date
______________________________________ ____________________
FSA CHR Signature Date
APPLICATION APPROVED: ________ APPLICATION DENIED: ________
REMARKS: ______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Revision2-03.03.2020
4-FSA-CHR
Fort Sill Apache Transportation Policy
Due to the number of people to be served, who reside within the program “service area” (see attachment), funding,
mileage and vehicles: CHR transportation is limited. The need is to economize on fuel expense and man power: therefore,
it has become necessary to establish the following formal Policies and Procedures regarding the need for transportation
from the Fort Sill Apache Community Health Representative Program.
THE CHR COORDINATOR HAS THE AUTHORITY TO DETERMINE IF TRANSPORTATION SHOULD OR
SHOULD NOT BE PROVIDED. Priority is given to clients who have neither transportation nor access to transportation
by family members or close friends. The CHR transportation should be your last resort.
1
st
Family or friends,
2
nd
Public transit or Sooner ride,
3
rd
CHR (The CHR program has the right to refuse service to anyone.)
The CHR Program WILL NOT:
Transport minors and/or person(s) that have been assigned a legal guardian without the accompaniment of the
parent(s) and/or said legal guardian. PROOF OF LEGAL GUARDIANSHIP MAY BE REQUIRED. Furthermore
the Fort Sill Apache CHR is NOT a babysitter. Minors are the responsibility of the parent(s) and/or said legal
guardian.
Transport any child that is not able to properly wear the seat belt without the aid of a Child Restraint System (car
seat) according to Child Passenger Safety recommendations and/or any child weighing 100 lbs. or less without a
PROPERLY installed Child Restraint System (car seat) in accordance with the state law. THE CHR PROGRAM
DOES NOT PROVIDE CAR SEATS.
Transport any person(s) who appear to be under the influence of alcohol and/or drugs. If the client seems to be
under the influence of alcohol/drugs during a transport, the CHR will notify the client that they will be
disqualified from the program indefinitely.
Transport any client who is thought to have a contagious condition that would put the CHR at risk. Clients who
we classify as “High Risk” include but limit to
A. Seriously ill with respiratory problems
B. Known to have seizures
C. Staph Infection
Transport a client that has the flu, or who has excessive vomiting and/or diarrhea.
Transport clients on shopping trips or errands that exceed more than 15 minutes. Reminder the CHR
transportation is not a taxi service.
Transport members of the client’s family without the approval from the CHR Coordinator.
Transport members of their own family without the approval from the CHR Coordinator.
Transport nursing home clients; as nursing homes are responsible for the health and welfare of their residents.
Transport clients who receive services from the VA, Social Services, or other mileage programs without the
approval from the CHR Coordinator.
Transport prenatal clients who are 8+months pregnant or who think they may be in labor. (Expecting mothers @
32 weeks must have family or close friends for the final weeks of pregnancy, including high risk pregnancy
mothers.)
Transport clients that have conditions that are life threatening or may require treatment. In this case an ambulance
must be utilized at the discretion and expense of the client. The CHR program is not an emergency form of
medical transportation (including but not limited to)
A. Heart attack
B. Gunshot wound
C. Insulin or Diabetic shock
D. Auto accidents
E. Severe head injuries.
Revision2-03.03.2020
5-FSA-CHR
Transport clients who are undergoing kidney dialysis and/or cancer treatments.
Transport a client that undergoing physical therapy and/or counseling. (case by case)
Transport any clients that have an open wound that seems to be uncared for and/or leaking bodily fluids.
Transport clients from any medical facility unless the Fort Sill Apache CHR program transported them there to
begin with. If a client was transported to a medical facility by ambulance, family member, or other form of
transportation, we will not be responsible for that clients return.
Transport a non-Fort Sill Apache tribal member from another “service area”, unless it has been approved from
that clients CHR “service area” Coordinator (Wichita, Apache, Caddo etc.) Only then depending on availability.
Transport when road conditions are hazardous or predicted to be hazardous, especially during inclement weather.
Transport on surgery day. If Anesthetic is being used during the surgery then the CHR program will not be
transporting. The CHR will transport on all appointments leading up the surgery (if available) but not on surgery
day.
Procedures, CHR and Clients Responsibilities.
The CHR program has some responsibilities to help you in any way that they can and make the services as easy,
understandable and comforting as possible.
The CHR will transport, pick up and/or drop off RX and/or medical supplies
The CHR can transport another Fort Sill Apache employee when approved by the Coordinator and
Administration.
The CHR will assist on scheduling Dr. appointments if the client is having a hard time doing so. (ex:
vision/hearing is impaired)
The CHR will be with the client the whole time (with prior approval) during the transport if need be for
support and communication/understanding needs. (ex: vision/hearing is impaired)
If the client gets admitted into the hospital the CHR will be with the client until the family is contacted about
the admission and to inform them of the situation if client is unable to.
The client must give over the phone and/or in application form (including but not limited to) full name, DOB,
address (directions to home if needed) phone number, CDIB, IHS chart numbers, proof of residence, list of
current RX being taken and emergency contact information. All clients are required to fill out the CHR
transportation application before services are provided.
The client will only utilize one CHR program. In the event it is discovered that the client is scheduling a
transport with more than one CHR program for unnecessary reasons, that client will be terminated from the
program for abuse of the CHR programs.
It is the client’s responsibilities to reschedule any missed appointments, with the medical facility and with the
CHR program if transportation is needed.
The CHR program will be notified of the needs for transportation at least three (3) days prior to appointment date. If
transportation is unavailable, the CHR program will refer the client to other CHR programs in the area and/or assist the
client with arranging another form of transportation as needed.
The Fort Sill Apache CHR program does implement the Probationary /Suspension Status for the “NO CALL, NO
SHOW” probation. Clients who miss a scheduled transport without notification,
A. 1
st
“no call no show” = SUSPENSION FOR 30 DAYS ( client will not be eligible for transport for the next
30 days)
B. 2
nd
“no call no show” = SUSPENSION FOR 60 DAYS (client will not be eligible for transport for the next 60
days)
C. 3
rd
“no call no show” = PERMANENT SUSPENSION FROM CHR PROGRAM.
The client will secure all pets on premises, and make sure there are no hazardous conditions in and around the
home from which the client will be picked up and dropped off. If pets are not secure or if the CHR realizes a
Revision2-03.03.2020
6-FSA-CHR
condition that is hazardous to themselves and/or the client, the CHR will not exit the vehicle and a reschedule
may be required.
The client will provide their own meals in the event the medical appointment last through a mealtime. A brief
stop may be made for the client (not to exceed 30 minutes)
A. If the stop is on route from the medical facility. The medical appointment has first priority
B. Only if time permits
C. At the discretion of the CHR
D. If the stop does not have an age limit to enter the facility (casino, smoke shop, bars and liquor stores.)
________________________________ __________________________
APLICIANT’S SIGNATURE DATE
________________________________ __________________________
CHR REPRESENATIVE DATE
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TRANSPORTATION FORM Transportation Form (Fort Sill Apache Tribe)

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Completed 27 January 2021

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