inHealth Medical Necessity

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)
Based on the above definition, is the patient bed confined? *

Yes No
Please list the medical condition, resulting in bed confinement: *

You indicated "Danger to self or others". Please elaborate on some of the specifics that make the patient dangerous. (You can also note here, what type of physical or chemical restraints are in place to safely transport this patient) *
You indicated "Third party assistance/attendant required to apply, administer or regulate oxygen during transportation". Please elaborate what condition prohibits the patient from self administering their oxygen treatment *
You indicated "Patient is confused, lethargic, combative or comatose". Please indicate what condition has contributed to this state *
You indicated "Non-healed fracture". Please indicate the location of the fracture and if it prohibits the patient from safely maintaining a seated position *
You indicated "Moderate to severe pain on movement". Please indicate what condition has contributed to this state and if pain management or special positioning is needed *
You indicated "Unable to maintain the seated upright position required for other means of transportation". Please indicate what condition has contributed to this state and if pain management or special positioning is needed *

Can this patient transport by other means? *

Other means of transportation are contraindicated because it would be harmful to the patients condition. Even if other means of transportation are available, ambulance trips are medically necessary and not for convenience This patient can transport in a car, wheel chair van or other means of transportation

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.
Name of Health Care Professional *

First Name Last Name
Healthcare Professional Signature *

Clear
Date *

Month Day Year
Title *

Physician Assistant Clinical Nurse Specialist Registered Nurse Nurses Practitioner Discharge Planner
Your Email
example@example.com
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