Medical Necessity Form For Ambulance - National Ambulance

425 Saint James Ave.

Phone: 413-736-0092

Springfield, MA 01109

Fax:

413-736-0079

PHYSICIAN’S CERTIFICATION OF MEDICAL NECESSITY FOR AMBULANCE TRANSPORTATION

Starting Date:_____/_____/_____

Ending Date:_____/_____/_____

Patient’s Name:_________________________________________________________

DOB:_____/_____/_____

Pick-Up Location:_______________________________________________________________________________

Facility

Street

City

State

Destination Location:____________________________________________________________________________

Facility

Street

City

State

Attending Physician Name / Address________________________________________________________________

Ambulance Transportation is medically necessary for the following reason(s):

Chief Complaints: Check At Least One

Obesity - Morbid

Shortness of Breath

Psychosis

__

__

__

(Unspecified)

278.01

786.05

298.8

(Requires Oxygen)

Suicidal Ideation

__

__

Decubitus Ulcers

V62.84

707.00

Fracture – Bone

__

829.0

Altered Mental Status

__

*Explain Below

Fatigue/Lethargic

780.97

__

780.79

Wound

__

__

Cerebrovascular Accident

879.6

434.91

Amputation – Leg Bilat

__

*Explain Below

897.6

CVA/Stroke

Amputation – Leg Nos

897.4

__

Pain

780.96

Convulsions

__

780.39

*Explain Below

__Gait Abnormality

(Unsteady)

781.2

Seizure Prone

Isolation/Precaution

__

V07.0

__

Weakness – Muscle

(General)

Coma

MRSA, VRE, TB, HEP

__

728.87

781.01

Secondary Complaints: Check All That Apply

Ventilator Dependant

__Unable to transfer from bed to

Violent, Combative or Confused

__

__

518.81

*MD signature required

stretcher without medical assistance

__Flight Risk: danger to self/others

*Explain Below

__Cardiac EKG Monitoring

428.9

__Unable to sit safely upright during transport

*MD signature required

__Restraints

(Physical/Chemical)

*Explain Below

IV Therapy/Drug Administration

__

__Requires Medical Supervision

__Hip Precaution/non-healing fracture

*MD signature required

*Explain Below

__Airway Monitoring/Suctioning

__Bed Confined

V49.84

*Explain Below

__Oxygen Dependence

Unable to get up from bed without assistance;

V46.2

Unable to ambulate; and

Unable to sit in a chair or wheelchair

Other Condition or Reason for Requiring Transportation by Ambulance: _______________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Signature:________________________________________________________________________

*Form must be signed only by patient’s attending physician for scheduled, repetitive transports and valid for 60 days from date above*

Print Full Name:_____________________________________________________

Please check appropriate designation below:

_____MD –Physician

_____DO-Physician

______Physician Assistant

______Nurse Practitioner

_____Registered Nurse

_____Discharge Planner

______Clinical Nurse Specialist

I have reviewed the above certificate and I have determined (I have received and oral/written order from the attending physician) for the above named patient/beneficiary that

ambulance transport and medical assistance/monitoring by EMT’s is medically necessary for the reasons stated above. I further believe that other means of transportation whether

available or not would be contraindicated, inadvisable and potentially injurious to this patient. I certify that the information contained herein is, to the best of my knowledge,

complete and accurate and supported in the medical record of the patient.

Revised 5/2015