Physician’s Medical Necessity Certification

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Physician’s Medical Necessity Certification

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SECTION I – GENERAL INFORMATION

Patient’s Name: *

Date of Birth: *

YYYY

Medicare # *

Initial Transport Date: *

YYYY

Repetitive Transport Expiration Date (Max 60 Days From Date Signed): *

YYYY

Address: Origin *

Address: Destination *

To be “bed confined” the patient must be: (1) unable to get up from bed without assistance; AND (2) unable to ambulate; AND (3) unable to ,sit in a chair or wheelchair

(Note: All three of the above conditions must be met in order for the patient to qualify as bed confined)

Is this patient “bed confined” as defined above? *

Yes

Describe the Medical CONDITION of this patient

AT THE TIME OF AMBULANCE TRANSPORTATION that requires the patient to be transported on a stretcher in an ambulance and why transport by other means is contraindicated by the patient’s condition:

3) Can this patient safely be transported in a wheelchair van? (i.e., seated for the duration of the transport, and without a medical attendant) *

Yes

Please check any of the following conditions that apply:
*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records

Contractures

Non-healed fractures

Moderate/severe pain on movement

Danger to self/others

IV meds/fluids required

Special handling/isolation required

Third party assistance/attendant required to apply, administer or regulate or adjust oxygen enroute

Restraints (physical or chemical) anticipated or used during transport

Patient is confused, combative, lethargic, or comatose

Cardiac/hemodynamic monitoring required enroute

DVT requires elevation of a lower extremity

Orthopedic device (backboard, halo, use of pins in traction, etc.) requiring special handling during transport

Unable to maintain erect sitting position in a chair for time needed to transport

Unable to sit in a chair or wheelchair due to Grade II or greater decubitus ulcers on buttocks

Morbid obesity requires additional personnel/equipment to safely handle patient

If this box is checked (below), I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient.

My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). 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:

Certification

Other:

Required

Printed Name of Healthcare Professional*

Date Signed

YYYY

Registered Nurse

Nurse Practitioner

Discharge Planner

Physician Assistance

Clinical Nurse Specialist

Please print and sign below

Signature of Physician* or Healthcare Professional

Submit

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