Non-Emergency Ambulance Request / Medical Necessity Form printable pdf download

United HealthCare Community Plan

West Region

Non-Emergency Ambulance Request / Medical Necessity Form

Fax completed form to: 901-795-0072

Phone: 901-405-0238

Today’s Date:_________________Patient’s County of Residence:________________

Patient’s Name: First________________________ Last________________________

Patient’s SSN:_______________________DOB:_____________Phone:____________

Patient’s Home Address: __________________________________________________

____________________________________________________________________

Date of Transport/Apt: ___________________ Time: __________________________

Requested Ambulance Service Name: _______________________________

PICKUP LOCATION:

DESTINATION:

___________________________________

_________________________________

(

(Full name of facility)

Full name of facility)

_____________________________Room #_____

_________________________Room#___

(Street Address)

___________________________________

_________________________________

(

(City, Zip, Phone#)

City, Zip, Phone#)

To be completed by the facility: Please check the appropriate conditions(s) listed below which would necessitate

transport by ambulance and thereby contradicting all other means of transport based on patient health and safety.

(Please check all that apply)

This patient:

__Is unable to get from bed without assistance, ambulate and sit in a chair, wheelchair

__Is not wheelchair able (can not stand, pivot, or ambulate and unable to assist themselves)

__Is comatose and requires monitoring

__Requires oxygen, no portable oxygen available

__This patient’s condition requires the use of restraints or is chemically restrained

__This patient has to remain immobile due to an unset fracture of the _____________

__Is frail/debilitated and at the time of service bed confined (Complete narrative)

__Is exhibiting signs of decreased or altered level of consciousness

__Is seizure prone and requires trained monitoring

__Suffers from paralysis and is bed confined

__Has decubitus ulcers and requires wound precautions

__Requires airway monitoring or suctioning

__Requires isolation precaution

(Narrative)_____________________________________________________________________________

___________________________________________________________________________________________________________

I certify that the above patient is suffering from an illness or injury that contraindicates transportation by any means

other than an ambulance, as indicated by the reasons for ambulance use checked above.

Name of Attending Physician:______________________________ Date:_________________

Signature of Authorized Individual:_________________________ ___RN ___Discharge Planner

___MD/DO ___PA

********FORM MUST BE SIGNED AND COMPLETED IN FULL*******

Non-Emergency Ambulance Request / Medical Necessity Form

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