MNF/PCS

Physician Certification Ambulance Statement
SECTION 1 - GENERAL INFORMATION
Patient's Name
DOB
Medicare #
Gender Assigned at Birth
Transport Date

MonthDayYear
Date
Origin
Destination
(Full) Physician Name
National Provider Identifier (NPI)
Closest Appropriate Facility?

YesNo
If no, why is transport to more distant facility required?
If hospital to hospital transfer, describe services needed at 2nd facility not available at 1st facility:
If hospice patient, is this transport related to patient's terminal illness?

YesNo
If no, please describe medical reason for hospice patient transport:
Section II - MEDICAL NECESSITY QUESTIONNAIRE
Describe the MEDICAL DIAGNOSIS (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires the patient to be transported BY AMBULANCE
Is the patient bed confined? To be bed confined, the patient must be unable to get up from bed without assistance, unable to ambulate and unable to sit in a chair. NOTE: Bed confinement alone does not meet the medical necessity for stretcher transport.

YesNo
Does the patient require special handling and/or positioning?

YesNo
If Yes to the above, please fill in all that apply:
Fracture of the: blanks
Anatomical positioning supervised during transport due to Fracture: blank
Decubitus Ulcer Location:   Type a label  Stage:   Type a label
Additional Decubitus Ulcer Location:   Type a label  Stage:   Type a label
Anatomical positioning supervised during transport due to Ulcer:   Type a label
Unable to sit or hold self in place, even with seatbelts, due to any of the followint?

ParalysisContracture
If Yes to above, please fill in the following:
Location of paralysis/contracture blanks
Additional Location of paralysis/contracture blank
Anatomical positioning supervised during transport Type a label
Is the patient exhibiting signs of decreased level of consciousness?

YesNo
If yes, what is reason for decreased LOC?
Does the patient require monitoring and/or treatment during transport for any of the following? Check all that apply.

Ventilator dependentIV Medications required enrouteECG Monitoring required enrouteOxygen Administration required enrouteSuctioning/Airway Control required enrouteSeizure Prone/Requires trained monitoring enrouteMedication requires trained monitoring enrouteChemical or Physical restraints required enroute
If yes to any of the following, please describe:
Vent Dependent, monitor for:blanks
IV Meds, monitor for:blank
ECG, diagnosis:   Type a label
O2 Required for:   Type a label
Restraints required due to:   Type a label
The patient requires one-on-one supervision due to any of the following, check all that apply:

Elopement riskDanger to self or othersDementia or Alzheimer's with altered mental status
The patient requires the following isolation precautions, check all that apply

Standard PrecautionsContact PrecautionsDroplet PrecautionsAirborne Precautions
Reason for Isolation Precautions
Other (Please list reason and what needs monitored during the transport)
Can only be moved by stretcher due to
Section III -SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL
I certify that the above information is true and correct based on my evaluation and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient's condition at the time of transport.
Signature of Physician* or Healthcare Professional (form can ONLY be signed by the patient's physician, nurse practitioner, or physician assistant for scheduled, repetitive transports)

Clear
Credentials (NOTE: LPN may not sign)

M.D. or D.O.Physician AssistantHealthcare ProfessionalRegistered NurseClinical Nurse SpecialistDischarge Planner
Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc)
Date Signed (For scheduled repetitive transport, this form is not valid for transports performed more than 60 days after this date)

MonthDayYear
Date
*Form must be signed only by patient's attending Physician, Nurse Practitioner, or Physician Assistant for scheduled, repetitive transports.
Should be Empty:

SECTION 1 - GENERAL INFORMATION

Section III -SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL

*Form must be signed only by patient's attending Physician, Nurse Practitioner, or Physician Assistant for scheduled, repetitive transports.