MEDICAL NECESSITY FORM B (PCS)

COMMUNITY HEALTH CARE AMBULANCE MEDICAL NECESSITY FORM (PCS)

CALL 901.321.0911 FOR TRANSPORTATION REQUEST
DATE OF SERVICE*

MonthDayYear

PATIENT / FACILITY INFO
PATIENT INFO
Patient Name*
First and Last
Social Security Number
Birth Date*

MonthDayYear
Gender*

MaleFemale
PICKUP FACILITY/ADDRESS
Pickup Facility*
Room Number
Room Number
Address*
Street Address, City, State, Zip
DESTINATION FACILITY/ADDRESS
Destination Facility*
Room Number
Room Number
Address*
Street Address, City, State, Zip

1. BED CONFINEMENT
BED CONFINED IS DEFINED AS THE PATIENT BEING: UNABLE TO GET UP FROM BED WITH OUT ASSISTANCE AND UNABLE TO AMBULATE AND UNABLE TO SIT IN A CHAIR OR WHEELCHAIR.

(ALL THREE ABOVE CONDITIONS MUST BE MET IN ORDER FOR THE PATIENT TO QUALIFY AS BED CONFINED. THE TERM BED CONFINED IS NOT SYNONYMOUS WITH "BED REST" OR "NON AMBULATORY" AND IS NOT THE SOLE CRITERIA FOR MEDICAL NECESSITY FOR AMBULANCE)
Is the Patient Bed Confined*

YesNo

2. HOSPITAL TO HOSPITAL TRANSPORT
SERVICES NOT AVAILABLE

Equipment/Procedure Not AvailableSpecialty Care Services Not Available
Explain
Choose

Psychiatric UnitIntensive Care UnitTrauma CenterNeuroBurn UnitOther

4. SIGNATURES
I certify that the above information is accurate based on my evaluation of this patient, and that the medical necessity provisions of 42 CFR 410.40(e)(1) are met, requiring that this patient be transported by ambulance. I understand this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services. I represent that I am the beneficiary’s attending physician; or an employee of the beneficiary’s attending physician, or the hospital or facility where the beneficiary is being treated and from which the beneficiary is being transported; that I have personal knowledge of the beneficiary’s condition at the time of transport; and that I meet all Medicare regulations and applicable State licensure laws for the credential indicated.
Patient Physically/Mentally Incapable of Signing

If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim form and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows:
Specific Reason(s) that the patient is physically or mentally incapable of signing:
Signature Of Physician Or Authorized Healthcare Professional*

Clear
Name of Physician or Authorized Healthcare Professional*
Date Signed*

MonthDayYear
Type of Authorized Healthcare Professional*

Physician AssistantClinical Nurse SpecialistLicensed Practical NurseCase ManagerNurse PractitionerRegistered NurseSocial WorkerDischarge Planner

Submit
Should be Empty:

COMMUNITY HEALTH CARE AMBULANCE MEDICAL NECESSITY FORM (PCS)

PATIENT INFO

PICKUP FACILITY/ADDRESS

DESTINATION FACILITY/ADDRESS