Doctor Forms

Contact:

Phone: (570) 538-4488 Fax: (570) 538-1556
Physician's Certification of Medical Necessity
Patient's Name

First NameMiddle NameLast Name
Expiration Date (60 days maximum)

MonthDayYear
Patient's Date of Birth

MonthDayYear
Date
Patient's Age
Patient's Sex
Patient's SSN
Transport Date

MonthDayYear
Transport From
Primary Diagnosis
Trip Type
Transport To
Secondary Diagnosis
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
NPI (National Provider Identifier)
Level of Care
Check All Applicable Boxes
Please document as much as possible about why the above patient requires ambulance transport:
The undersigned certifies that he/she is familiar with the patient's condition and has reviewed the foregoing Certification to determine that ambulance transportation is medically necessary for the reasons specified.
Physician's or Other Authorized Signature
Physician's full Name

First NameLast Name
Physician's Title
Today's Date

MonthDayYear
Additional Information Added by Transportation Provider and or Billing Staff:
Should be Empty:

Contact: