Trauma Fund 2019 APRIL
This is for care provided from July 1, 2017 to December 31, 2017.
To apply for Trauma Fund you must submit a complete application by the designated deadline.
To download your items for your application package:
1. Identify your provider type (EMS, Hospital or Physician).
2. Select the correct section.
3. Download the items you need by clicking on the correct items
NOTE: APPLICATION DEADLINES ARE DIFFERENT FOR EACH PROVIDER TYPE. See respective Letter of Invitation for deadline.
Emergency Medical Services (EMS) Application
Letter of Invitation (288 KB pdf)
Checklist for Submission (22.4 KB pdf)
Memorandum of Agreement, MOA (54.6 KB pdf)
EMS Clinical Criteria (12.9KB pdf)
EMS Claim Form (2010.xlsx 24.8 KB)
EMS Financial Instructions (509.5 KB pdf)
EMS Worksheet (18KB .xlsx)
EMS Step-By-Step Guide (29.6 KB pdf)
Letter of Invitation (586 KB pdf)
Checklist for Submission (58.4 KB pdf)
Memorandum of Agreement MOA (58.4 KB pdf)
Hospital Clinical Criteria (13.5 KB pdf)
Hospital Claim Form (24.8KB .xlsx)
Hospital Claim Form (sample) (12.9 KB pdf)
Hospital-Major Trauma Case List Response Form (sample)(38.8 KB pdf)
Hospital Financial instructions (23.4 KB pdf)
Hospital Step-By-Step Guide (54.10 KB pdf)
Letter of Invitation (565 KB pdf)
Checklist for Submission (22.8 KB pdf)
Memorandum of Agreement, MOA (58.4 KB pdf)
Physician Clinical Criteria (14.91 KB pdf)
Physician Claim Form (2010.xlsx 35.3 KB)
Physician Step-By-Step Guide (50.78 KB pdf)
Please e-mail your questions to email@example.com or contact our office at (405) 271-4027.