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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

Round TripOne Way
Transport To
Secondary Diagnosis
Phone Number
Please enter a valid phone number.
NPI (National Provider Identifier)
Level of Care*

BLSALS-1ALS-2CCT / SCTAir Ambulance / Emergency Required
Check All Applicable Boxes*

Patient is or may need to be restrainedPatient has visible hemorrhagingPatient is on a psychiatric holdPatient needs to remain immobile due to a FXPatient has an IV in place (does not include hep-locks)Patient is Ventilator dependentPatient requires vital signs to be monitoredPatient is unconscious or in shockPatient had an acute MI (within the last 8 weeks)Patient requires oxygen that may need to be titratedThere are no beds available at sending facilityPatient was given meds prior to transportPatient unable to control secretions / Suctioning may be requiredPatient requires a cardiac monitor or other specialty equipmentPatient has decubitus ulcers / open wounds and req wound precautions (to include repositioning of patient)Patient has wandering tendencies and req monitoring for safety (Alzheimer’s, Dementia, OBS, etc.)Patient t had a FX hip or total hip replacement and is still utilizing a wedge for immobilizationPatient has an infection that requires isolation precautions (MRSA,VRE,TB, Meningitis, Hepatitis)There are services available, but the Patient’s condition is too grave to wait (emergency transport)It would place the patient in danger to transport them by any other meansIt would be a COBRA violation to transport the patient by any means other than an ambulancePatient is bed confined: The patient is unable to get out of bed without assistance. Patient is also unable to sit in a chair or wheelchair
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*

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Physician's full Name

First NameLast Name
Physician's Title*
Today's Date*

MonthDayYear
Additional Information Added by Transportation Provider and or Billing Staff:
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Contact:

Physician's Certification of Medical Necessity