Physician Certification Statement For Non-Emergency Ambulance Services Form

Phone : 765-396-9483

Intake Fax: 765-396-4429

Billing Fax: 765-396-4427

Physician Certification Statement for Non-Emergency Ambulance Services

SECTION I – GENERAL INFORMATION

Patient’s Name:

______

___________

(Place sticker here)

Date of Birth: ________________ SSN:____________________________________

Medicare #:

Medicaid #:______________________

Is the pt’s stay covered under Medicare Part A (PPS/DRG?)  YES

 NO

Additional Insurance__________________________________ Policy #_________________________ Group #___________________________

* This PCS is valid for all trips on the date of transport (i.e., round trips) and for scheduled/repetitive trips in a 60-day range.

SECTION II – MEDICAL NECESSITY QUESTIONNAIRE

Describe the PHYSICAL OR MENTAL CONDITION of this patient AT THE TIME OF AMBULANCE TRANSPORTATION that requires

the patient to be transported on a stretcher in an ambulance and why transport by other means is contraindicated by the patient’s

condition:

_______________________

________________

____________________________________________________________________________________________________________________

Is this patient “bed confined”?

 Yes

 No

To be “bed confined” the patient must be: (1) unable to get up from bed without assistance; AND (2) unable to ambulate;

AND (3) unable to sit in a chair or wheelchair (Note: All three of the above conditions must be met in order for the patient

to qualify as bed confined.)

Can this patient safely be transported by car or wheelchair van without a medical attendant or monitoring?

 Yes

 No

In addition to completing questions 1-3 above, please check any of the following conditions that apply:

 Contractures

 Non-healed fractures

 Moderate/severe pain on movement

 Danger to self/others

 IV meds/fluids required

 Special handling/isolation required

 Patient is confused, combative, lethargic, or comatose

 DVT requires elevation of a lower extremity

 Third party assistance/attendant required to apply, administer or regulate or adjust oxygen enroute

 Restraints (physical or chemical) anticipated or used during transport

 Cardiac/hemodynamic monitoring required enroute

 Orthopedic device (backboard, halo, use of pins in traction, etc.) requiring special handling during transport

 Unable to maintain upright sitting position in a chair for time needed to transport

 Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds on buttocks

 Morbid obesity requires additional personnel/equipment to safely handle patient

 Other (specify)

SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL

I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by

ambulance due to the reasons documented on this form. I understand that this information will be used by the Centers for Medicare and Medicaid

Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the

patient’s condition at the time of transport.

_____

________________

Signature of Physician* or Healthcare Professional

Date

PRINT NAME AND CREDENTIALS (MD, RN, etc.)

*Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, the

form may be signed by any of the following if the attending physician is unavailable to sign (please check appropriate box below)

 Physician Assistant

 Clinical Nurse Specialist

 Registered Nurse

 Nurse Practitioner

 Discharge Planner

Physician Certification Statement For Non-Emergency Ambulance Services Form - Eaton Emts

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