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  • Medical Necessity Certification Statement for Non-Emergency Ambulance Services - Version 2.0

    SECTION I - GENERAL INFORIATION

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  • 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:

  • SECTION III - SIGNATURE OF PHYSICIAN OR OTHER AUTHORIZED HEAITHCARE PROFESSIONAL

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  •  *Form must be signed only by patient's attending physician for scheduled, repetitive transports. For non-repetitive ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below):

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