LeRoy Emergency Ambulance Service Inc.

A proud partner in our community´╗┐...

Transfer Information:

To Schedule a transfer call (309) 962-6114


Transfer Checklist:

Every Transfer Must have the following:

- PCS (Physicians Certification Form

- Face Sheet

- Pt History, Medication, and Allergies

The Following May be required when applicable:

- SASS/ Crisis Notes

- DNR

- A copy of the Involuntary Admit Form


Medicaid Only

- MCA (Medical Certificate for Non-Emergency Transport: Only needed if being discharged from the hospital)


(Please make sure to print the form and confirmation)