Name (Last, First MI)

Date of Birth

Medicare Num

Date of Transfer

Origin

Destination

Is the Patient’s stay covered under Medicare Part A (PPS/DRG?)

Closest appropriate facility?

If no, why was the patient transported to another facility?

If hospital to hospital transfer, describe services needed at 2nd facility not available at 1st facility

If hospice Pt, is this transport related to Pt's terminal illness?

Name of hospice agency providing care

Please describe patients hospice-qualifying condition

Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either "bed confined" or suffer from a condition such that transport by means other than an ambulance is contraindicated by the patient's condition. The following questions must be answered by the healthcare professional signing below for this form to be valid:

(1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires the patient to be transported in an ambulance, and why transport by other means is contraindicated by the patient's condition:

(2) Is this patient "bed confined" as defined below?

(3) Can this patient safely be transported by other means (auto, wheelchair van, etc) (i.e., may safely sit during transport, without an attendant or monitoring?)

Please verify that this patient is being transported for the convenience of the facility vs. medical services not available at the facility.

If other, specify details:

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.

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

Full Name and Credentials of Physician or Authorized Healthcare Professional (MD, DO, RN, etc.)

*Form must be signed only by patient's attending physician for scheduled, repetitive transports. For non-repetitive ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below):