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


- 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)