PHYSICIAN CERTIFICATION STATEMENT
For ALL Non Emergency Medical Transportation Services
Transport Date: ____/____/_____ Certification Expiration Date (Max 60 days) _____/_____/_____
(PCS effective for 60 days for repetitive transports or for a single prescheduled or unscheduled transport only.)
Patient's Name: ___________________________________________________ Medicare #: _______________________
Patient’s Address: _________________________________________________ Medicaid #: _______________________
Street
____________________________________________
City State Zip
Transported From: ________________________________________ Transported To: ____________________________________
Physician's Printed Name: __________________________________ License # or UPIN #: ________________________________
In my professional medical opinion, this patient does not require transport by ambulance and can safely be transported by other means.
The patient's condition is such that transportation by ambulance is not required because the means listed below is safe and acceptable.
[ ] Patient can safely support himself / herself while seated in wheelchair and does not require monitoring by Trained personnel.
[ ] Patient is able to tolerate transportation by automobile or wheelchair van.
In my professional medical opinion, this patient requires transport by ambulance and should NOT be transported by other means.
The patient's condition is such that transportation by medically trained personnel is required.
The CMS definition of Bed-Confinement is: The inability to get up from bed without assistance; unable to ambulate; and unable to sit in a chair, including unable to sit in a wheelchair independently. (ALL MUST BE MET)
Does this patient meet CMS definition of bed confinement ? Yes ? No
If patient does not meet the definition but still requires ambulance the reason must be detailed below.
Please check the appropriate medical conditions listed below which would necessitate transport by ambulance and
make all other means of transportation contraindicated based on patient safety and health.
This patient: ** (A) - MUST BE DEFINED IN EXPLANATIONS **
[ ] requires continuous oxygen & monitoring by trained staff [ ] has decubitus ulcers and requires wound precautions (A)
[ ] requires airway monitoring and suctioning [ ] requires isolation precautions (VRE,MRSA, etc) (A)
[ ] requires restraints or sedation (A) [ ] patient requires continuous IV therapy
[ ] comatose & requires trained monitoring [ ] requires cardiac monitoring
[ ] is actively seizure prone & requires trained monitoring [ ] is exhibiting signs of a decreased level of consciousness (A)
[ ] had to remain immobile because of a fracture/possibility of
a fracture which had not been set [ ] is on hip precautions and cannot sit safely (A)
[ ] patient is ventilator dependent [ ] Other (A)
[ ] patient cannot sit erect in a wheelchair for the duration of the transport due to a reasonable probability that this may potentially either
cause pain and/or further medical complications. (A)
Diagnosis: _____________________________________________________________________________________________________
A (Explanations in detail are required)______________________________________________________________________________
____________________________________________________________________________________________________
If patient is being transferred for care not available at 1st facility, what care / treatment are they being transferred for?
______________________________________________________________________________________________________________
PATIENT IS TO RECEIVE THE FOLLOWING TREATMENT after transport: (Please check one)
[ ] Receive treatment in an outpatient setting [ ] Require admission to hospital [ ] Transferred from one medical facility to another
I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS, TO THE BEST OF MY KNOWLEDGE, COMPLETE AND ACCURATE AND SUPPORTED
IN THE MEDICAL RECORD OF THE PATIENT. THE INFORMATION BEING UTILIZED ON THIS FORM IS BEING GATHERED TO ASSIST IN
SEEKING REIMBURSEMENT FROM THIRD PARTY PAYORS SUCH AS THE MEDICARE AND / OR MEDICAID PROGRAM. I UNDERSTAND THAT ANY
INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION, WHICH LEADS TO INAPPROPRIATE PAYMENTS, MAY BE
SUBJECT TO INVESTIGATIONS UNDER APPLICABLE FEDERAL AND/OR STATE LAWS.
___________________________________________________ ________________________________________________
Printed name of Ordering Physician, PA, NP, CNS, RN, or Discharge Planner & Title Signature Date Signed
________________________________________________________ _____________________________________________________
Printed Name of Recipient Signature Date Signed
___________________________________________________ _______________________________________________
Printed Name of Medical Transportation Provider Signature Date Signed