Schedule Ambulance

Location:

Requester Information:

Patient Information:

Physician Information:

Form Instructions:

  • This form must be completed in its entirety.
  • The patient’s condition at the time of transport must be documented.
  • Medical Necessity criteria must be clearly documented according to CMS PCS requirements.
  • If this PCS is for a repetitive patient (identified as a patient requiring three (3) or more transports within a ten (10) day period), a physician must sign this form prior to the first transport. This form may serve for a period of sixty (60) days.
  • Medicare requires under 42CFR, Part 401.40(d) that ambulance providers obtain a Physician’s Certification Statement (PCS), signed by a listed clinician, for the provision of non-emergency transportation. This form has been designed to assist clinicians, Medicare beneficiaries, and ambulance provider in determining if medical necessity has been met. Authorized signers please complete the medical necessity section of this form and then sign the form, listing your credential.

Medical Necessity Criteria:

To be completed by a clinician who is employed or contracted by the facility where the beneficiary is being treated, and who has knowledge of the beneficiary’s condition at the time the transport was ordered or the service was being furnished.

(*) Asterisked fields require additional information.

Clinician’s Information: