• inHealth Medical Necessity

  •  /  / Pick a Date
  • A patient is bed confined if they are unable to get up from bed without assistance, unable to ambulate and unable to sit in a chair. Ref. 42 CFR 410.40(d)(1)

  • If the patient is not bed confined, what constitutes the need for ambulance transportation?

  • Identify further information regarding the patients need for an ambulance for transportation if applicable

  • I certify that the information contained herein is, to the best of my knowledge, complete, accurate and supported in the patient's medical record. The information being utilized on this form is being gathered to assist in seeking reimbursement from the Medicare program. I understand that any intentional misrepresentation, falsification or essential information which leads to inappropriate payments, may be subject to investigations under applicable federal and/or state laws.
  • Clear
  •  /  / Pick a Date
  • Should be Empty: