Patient First Name* Patient Last Name* is scheduled to be transported by S.T.A.R., Inc. on Date* from our facility facility name* to destination name* and returned.
It is medically necessary for the above patient to be transported by ambulance only. If Medicare denies the claim due to lack of medical necessity, then our facility will be financially responsible for paying for this ambulance transportation.
I, First Name* Last Name* Title* , have the authority to approve payment to S.T.A.R., Inc. if Medicare denies this claim.