Home / Resources Hospitals Reporting A PEC If you are a medical staff member needing to report a PEC, please fill out all the information below Patient's Name(Required) Patient First Name Patient Last Name Race(Required)Select An OptionWhiteBlackHispanicAsianNativePacificOtherSex(Required)Select An OptionFemaleMaleOtherDate of Birth(Required) MM slash DD slash YYYY Age(Required)Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PEC Issued By(Required)Date Signed(Required) MM slash DD slash YYYY Time Signed(Required) Hours : Minutes Note: Use 24 Hour TimeDate Admitted(Required) MM slash DD slash YYYY Time Admitted(Required) Hours : Minutes Note: Use 24 Hour TimeRoom #(Required)Unit/Floor(Required)Reporting Medical Staff Member(Required) First Last Staff Member Hospital(Required)Select An OptionBrentwoodChristus HighlandIntensive SpecialtyLA Behavioral Health/OceansNorth Caddo Medical CenterOchsner-LSUOchsner-St MaryPhysician's BehavioralVAWillis Knighton-BossierWillis Knighton-NorthWillis Knighton-PierremontWillis Knighton-SouthWKBMed/WKRIStaff Member Phone(Required)You will be able to download a receipt after clicking Submit. Δ
