Physician Certification Statement

Physician Certification Statement
Patient Last Name:*
Patient First Name:*
Middle Name:
DOB:*
Medicare #:
Transport Date:*
(Valid for round trips this date, or for scheduled repetitive trips for 60 days from date signed below.)
Origin:*
Destination:*
Pickup Location: *
Unit and/or Room Number
Drop Off Location: *
Unit and/or Room Number
Is the Patient's stay covered under Medicare Part A (PPS/DRG?)
Closest appropriate facility?*
If no, why was the patient transported to another facility?*
If hospital to hospital transfer, describe services needed at 2nd facility not available at 1st facility: *
If hospice Pt, is this transport related to Pt’s terminal illness?
If NO, Describe:
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:
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:
Is this patient “bed confined” as defined below?*
To be "bed confined" the patient must satisfy all three of the following criteria: (1) unable to get up from bed without assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair.
Can this patient safely be transported by car or wheelchair van (i.e., may safely sit during transport, without an attendant or monitoring?)*
ContracturesNon-healed fracturesPatient is confusedPatient is comatoseNeed, or possible need, for restraintsModerate/severe pain on movementDanger to self/othersIV meds/fluids requiredPatient is combativeNeed, or possible need, for restraintsDVT requires elevation of a lower extremityMedical attendant requiredRequires oxygen – unable to self-administerSpecial handling/isolation/infection control precautions requiredUnable to tolerate seated position for time needed to transportHemodynamic monitoring required enrouteUnable to sit in a chair or wheelchair due to decubitus ulcers or other woundsCardiac monitoring required enrouteMorbid obesity requires additional personnel/equipment to safely handle patientOrthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transportOther
Other (specify)
SECTION III – SIGNATURE OF PHYSICIAN OR OTHER AUTHORIZED HEALTHCARE PROFESSIONAL
I certify that the above information is accurate based on my evaluation of this patient, and that the medical necessity provisions of 42 CFR 410.40(e)(1) are met, requiring that this patient be transported by ambulance. I understand this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services. I represent that I am the beneficiary’s attending physician; or an employee of the beneficiary’s attending physician, or the hospital or facility where the beneficiary is being treated and from which the beneficiary is being transported; that I have personal knowledge of the beneficiary’s condition at the time of transport; and that I meet all Medicare regulations and applicable State licensure laws for the credential indicated
Printed Name and Credentials*
Date*
Printed Name and Credentials of Physician or Authorized Healthcare Professional (MD, DO, RN, etc.)
Physician AssistantNurse PractitionerClinical Nurse SpecialistRegistered NurseLicensed Practical NurseSocial WorkerCase ManagerDischarge PlannerMedical DoctorDoctor of Osteopathic Medicine
Signature and Credentials

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Physician Certification Statement

SECTION II – MEDICAL NECESSITY QUESTIONNAIRE

SECTION III – SIGNATURE OF PHYSICIAN OR OTHER AUTHORIZED HEALTHCARE PROFESSIONAL

Printed Name and Credentials of Physician or Authorized Healthcare Professional (MD, DO, RN, etc.)