Use this form to refer a patient to the Community EMS program. Please complete all required fields and provide as much relevant information as possible to help us review the referral and coordinate appropriate services.

Once completed, submit the referral using the instructions below or send it to:

Community EMS
Secure Fax: 608-798-1839

 Secure Email: chief@crossplainsems.com

A member of our Community EMS team will review the referral and follow up as appropriate.

Community EMS form.pdf