Physician Certificate of Medical Necessity

PHYSICIAN CERTIFICATE OF MEDICAL NECESSITY

This Medicare certification form is required for all scheduled (24 hr advance notice), routine patient transport including recurring transports for patients required for DIALYSIS, HBO, RADIATION THERAPY, PHYSICAL THERAPY, etc., and non-scheduled transports such as discharges. NON-EMERGENCY TRANSPORT ONLY.

Patient Demographics:

Patient Name: / Room Number: / Diagnosis:
Medicare Number: / Date of Birth: / Social Security Number:
Origin: / Date of Transfer: / Destination:
¨  Scheduled Transport
¨  Non-scheduled Transport / Time: / Attending Physician:

Ambulance transportation is medically necessary for the following reasons (SELECT ONE):

¨  1. BED CONFINED – The patient is: (ALL 3 MUST APPLY):
¨  Unable to get up from bed without assistance; AND
¨  Unable to ambulate; AND
¨  Unable to sit in a chair or wheelchair (without restraints) / ¨  2. Stretcher only. Other means of transport are contraindicated because it would be harmful to the patient’s condition. (Significant medical documentation must accompany these claims). / Please provide a narrative description of patient’s medical condition requiring the use of an ambulance for transportation. (Please specify.)

Please select ALL PHYSICAL CONDITIONS that qualify the patient for ambulance opposed to other means:

¨  Decreased level of consciousness
¨  Combativeness/Risk of Self Endangerment
¨  Contractures
¨  CVA w/paralysis
¨  Decubitus/ulcers
¨  Degenerative Aging Process
¨  End Stage Disease / ¨  Fetal positioning
¨  Hemorrhaging
¨  Head injury
¨  Isolation Patient
¨  Quadriplegia
¨  Severe pain or Distress exacerbated with exertion on movement / ¨  Terminal condition
¨  Total Hip replacement
¨  Unconscious/comatose
¨  Unstable fracture/Possibility of fracture
¨  Vegetative state
¨  Severe weakness 2nd to

If the patient requires transportation based on the need for the continual medical supervision, and any other means of transportation would be contraindicated because it may endanger or exacerbate the patient’s condition, please select ALL of the following services that apply and give any specifics on the line provided:

¨  Airway Management
¨  Isolation Precautions
¨  IV Therapy/Monitoring
¨  Medication Monitoring/Administration
¨  Restraints
¨  EKG Monitor
¨  Sedation/Chemical Restraints
¨  Wound Precautions / ¨  Fall Precautions
¨  Flight Risk
¨  Immobilization
¨  Oxygen Therapy
¨  Body Cast
¨  Seizures Precautions
¨  Vent Dependent / ¨  Other/Specify

I certify that the information listed above represents an accurate assessment of the patient’s status and ambulance services are necessary, effective for 60 days.

Physician: ______UPIN#: ______Date: ______

Please type or print

Physician’s signature (required): ______Phone: ______

I certify that the attending Physician has given me oral or written order to authorize ambulance transportation.

RN, NP or PA: ______Title: ______Date: ______

Please type or print