NEW HAMPSHIRE MEDICAID

MEDICAL NECESSITY FOR AMBULANCE SERVICES

*** All Information Must Be Complete and Legible ***

RECIPIENT INFORMATION
Recipient Name: / Medicaid/Insurance ID #: / DOB: ____/____/____
Dispatch Date(s): / Start Date: _____/_____/_____End Date: _____/_____/_____
For scheduled routine appointments, use the dates indicated on the Authorization Request Form (Form 272AMB)
Locations: / Transported From: Taken To:
AMBULANCE PROVIDER INFORMATION
Provider Name: / Provider Medicaid #:
MEDICAL NECESSITY FOR AMBULANCE TRANSPORTATION
Was the recipient ambulatory? /  YES NO
Could other means of transportation have been used without endangering the patient’s condition? /  YES NO
Is the Recipient “Bed Confined”? YES NO
Must meet all three conditions: (1)unable to get up from bed without assistance; and(2)unable to ambulate; and (3)unable to sit in a chair or wheelchair.
The physical/mental condition that necessitates transport by ambulance and why other means of transport is contraindicated:
If applicable, the reason patient was transferred from one institution to another:
AMBULANCE SERVICES PROVIDED
Check appropriate box: BLS ALS (provide details below)
Suspected diagnosis or presenting symptoms: (complete only when ALS services are provided)
 Chest pain Respiratory Arrest Respiratory Distress  Dizziness or Syncope Unconscious
 Burns Shock Seizures OD/Poison
 Other (Describe): ______
ALS Care Provided: (complete only when ALS services are provided)
 Placement Extrication Endotracheal Tube Placement EKG (circle one): Monitor / Telemetry
 CPR  Defibrillation I.V. Therapy
SCHEDULED AND ROUTINE AMBULANCE TRANSPORTATION(If applicable)
Reason for the Transport: Medical Appointment  X-rays  Chemotherapy/Radiation Treatment  Diagnostic Lab Services
 Dialysis  Other (describe:)______
MEDICAL CERTIFICATION FOR AMBULANCE TRANSPORTATION
I certify that I have personal knowledge of the recipient’s condition. I further certify that the above information is true and correct based on my evaluation, and represents that the recipient requires transport by ambulance. I understand that this information will be used to support the determination of medical necessity and payment for ambulance services by the NH Medicaid program.
______
Signature of Healthcare Provider
______
Printed Name of Healthcare Provider / MD DO PA CNS APRN RN LPN Discharge Planner
Healthcare Provider Credentials
______
Date Signed
Signature must be provided by one of the following: Attending Physician (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Clinical Nurse Specialist (CNS), Advanced Practice Registered Nurse (APRN), Registered Nurse (RN), License Practical Nurse (LPN), or a Discharge Planner employed by the facility where the recipient is being treated.

Approval is a determination that the services requested are medically necessary and not a guarantee of payment.

Please Forward This Form and All Supporting Documentation To:

Schaller Anderson ■ 8 Commerce Drive ■ Second Floor ■ Bedford, NH 03110

FAX: (866) 499-9334 ■ PHONE: (866) 499-9335