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Address 1*
Apt./Floor
City*
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Address Type*
Save Address Save Address
         
First Name*
Last Name*
DOB
Phones*
Home Phone
Mobile Phone
Work Phone

Client Addresses

           
Carrier*
Policy #*
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End
Save Insurance


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Number

Insurance

Policy

Date Start

Date End

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Secondary Name Address
Tertiary Name Address
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MEDICAL HISTORY
ALLERGIES

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SERVICES
SmartEMS is strictly a mobile application that provides dispatch functions. SmartEMS does not operate any transportation services in any capacity and relies solely on third party State DOH certified providers.

- It is the client’s responsibility to confirm on the APP that an ambulance has been dispatched. If you are unable to get confirmation via the APP, call our dispatch center at 888-804-SMART (7627).

HOSPITAL OF CHOICE
SmartEMS will coordinate with its third party EMS transportation providers to accommodate that the patient is transported to their hospital of choice. However, it is the decision of the transportation provider to decide if the patient is physically stable to be transported to that facility based on the local DOH protocols.

HIPAA
SmartEMS will provide Business Associate Agreements with its third party providers.

ETA
The ETA provided is an approximate time of arrival; there shall be no liability for late arrival due to any factor.

LIABILITY
Liability shall be limited to the amount paid for services and SmartEMS shall not be responsible for malfunction and delays of mobile system (the APP) or lack of service provided by third party. If you are unable to place the request via the app, please call 911.

PAYMENT
SmartEMS is not responsible for any costs you may incur as a result of using mobile devices or data etc. You are responsible for any billings by third party providers. These charges are generally covered by third party insurance, however you will be responsible for any uncovered costs.

INFORMATION
Medical History and ALL information inputted MUST be updated, accurate and complete prior to placing a request. SmartEMS is not responsible for anything that results due to inaccurate information provided at the time a transportation request was made.


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