PHYSICIAN CERTIFICATION STATEMENT FORM

SECTION I:

GENERAL INFORMATION
PATIENT FULL NAME:*

FIRST NAMEMIDDLE INITIALLAST NAME
DATE OF BIRTH:*

MonthDayYear
IS THE TRANSPORT BEING PRE-SCHEDULED?*
TRANSPORT DATE
PRE-SCHEDULED TRANSPORT DATE:
SENDING LOCATION:*
SENDING LOCATION - ROOM NUMBER:*
EXAMPLE: EMERGENCY DEPARTMENT / ROOM: 3
DESTINATION LOCATION:*
DESTINATION LOCATION - ROOM NUMBER:*
EXAMPLE: EMERGENCY DEPARTMENT / ROOM: 3
CLOSEST APPROPRIATE FACILITY?*

YESNO
IF NO, WHY WAS THE PATIENT TRANSPORTED TO ANOTHER FACILITY?*
PLEASE DESCRIBE / WHY THE PATIENT NEEDS TO GO TO A DIFFERENT FACILITY WHEN THERE IS AS LOCAL FACILITY!
IS THE PATIENT’S STAY COVERED UNDER MEDICARE PART A (PPS/DRG)?*

YESNO
IF YES, MEDICARE #:*
HOSPITAL TO HOSPITAL TRANSFER, PLEASE DESCRIBE SERVICES NEEDED AT 2ND FACILITY NOT AVAILABLE AT 1ST FACILITY:
PLEASE SELECT OR TYPE THE SERVICES THAT ARE NOT AVAILABLE AT THE 1ST FACILITY
IF HOSPICE PATIENT, IS THIS TRANSPORT RELATED TO PATIENT'S TERMINAL ILLNESS)?*

YESNO
IF YES, DESCRIBE THE TERMINAL ILLNESS:*

SECTION II :

MEDICAL NECESSITY QUESTIONNAIRE
AMBULANCE TRANSPORTATION IS MEDICALLY NECESSARY ONLY IF OTHER MEANS OF TRANSPORT ARE CONTRAINDICATED OR WOULD BE POTENTIALLY HARMFUL TO THE PATIENT. TO MEET THIS REQUIREMENT, THE PATIENT MUST BE EITHER “BED CONFINED” OR SUFFER FROM A CONDITION SUCH THAT TRANSPORT BY MEANS OTHER THAN AN AMBULANCE IS CONTRAINDICATED BY THE PATIENT’S CONDITION. THE FOLLOWING QUESTIONS MUST BE ANSWERED BY THE HEALTHCARE PROFESSIONAL SIGNING BELOW FOR THIS FORM TO BE VALID:
1. DESCRIBE THE MEDICAL CONDITION (PHYSICAL AND/OR MENTAL) OF THIS PATIENT AT THE TIME OF AMBULANCE TRANSPORT THAT REQUIRES THE PATIENT TO BE TRANSPORTED IN AN AMBULANCE, AND WHY TRANSPORT BY OTHER MEANS is CONTRAINDICATED BY THE PATIENT'S CONDITION:*
EXAMPLE: UNCONSCIOUS / ALTERED MENTAL STATUS
TO BE “BED CONFINED” THE PATIENT MUST SATISFY ALL THREE OF THE FOLLOWING CRITERIA:

(1) UNABLE TO GET UP FROM BED WITHOUT ASSISTANCE

(2) UNABLE TO AMBULATE

(3) UNABLE TO SIT IN A CHAIR OR WHEELCHAIR
IS THE PATIENT BED CONFINED?*

YESNO
CAN THIS PATIENT SAFELY BE TRANSPORTED BY CAR, WHEELCHAIR, VAN (I.E. MAY SAFELY SIT DURING TRANSPORT WITHOUT AN ATTENDANT OR MONITORING)?*

YESNO
IN ADDITION TO COMPLETING QUESTIONS ABOVE, PLEASE CHECK ANY OF THE FOLLOWING CONDITIONS THAT APPLY*

*NOTE: SUPPORTING DOCUMENTATION FOR ANY BOXES CHECKED MUST BE MAINTAINED IN THE PATIENT’S MEDICAL RECORDS SECTION II:
PLEASE SELECT THE FOLLOWING CONDITIONS THAT APPLY:

SECTION I:

SECTION II :

SECTION III: