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AMBULANCE NON-EMERGENCY AND DIALYSIS TRANSPORTS
Certification of Medical Necessity

DATE:_______________ FN=Form-AmbNecessity.DOC   Front side Click here to see the BACK SIDE

Beneficiary Name:

  

Medicare HIC Number:

  

Date of Birth:

  

Name of Ordering Physician:

  
oYes oNo

Is patient ambulatory with assistance?

oYes
oNo

Is patient able to sit erect for duration of transport without pain and/or possibility of further injury?

oYes
oNo

Can patient safely make transfers from bed to chair with assistance? How many attendants required_______
oYes oNo

Is patient totally bedridden? On what date?____________________

If the answer is no to either of the two middle questions, llease elaborate here. Also include any other comments concerning the patient’s need for ambulance transport rather than transport by other means PLEASE BE VERY SPECIFIC

   

 

CVA paralysis(whatextent)?__________________________Date______________

Contracture(what extent)?_____________________________________________

Amputations(what extent does patient have prosthesis(es)) ________________________________________________________________________

Severe Illness?____________________________________Date_______________

Do you reasonably expect patient’s status as described above will improve within the next six months? oYes     oNo

I understand that falsification of a patient’s medical necessity for ambulance transport constitutes fraud and that the above information is correct to the best of my knowledge oPhysician    oNurse    oEMT B/I/P    oFamily

______________________________Signature _______________Date