Medical Necessity Certification Statement
for
Non-Emergency Ambulances Services

1204 East High Street
Davenport, IA  52803
Phone: (563) 323-1000
Fax: (563) 326-4988
Section 1 - General Information
Patient Name: DOB: Patient's SSN: Patient's
Weight:
Origin:


Destination: 


Date of the Transport:

Repetitive Transport Expiration Date:
 

Enter Name of Person Arranging Transport: Call Back Phone#:
Call Back Fax#:
Enter Name of Person Completing Form: Call Back Phone#:Contact Phone# for Person Completing Form:
 
     
  
Section 2 - Medical Necessity Information for Non-Emergency Transportation
 
A. Can the Patient by safely transported by car, taxi, bus or a wheelchair van?   YES   NO If YES, ABN Required
B. Please 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:
C. Is the Patient able to get up from bed without assistance?  YES   NO If NO, describe why:
D. Is the Patient able ambulate?  YES   NO If NO, describe why:
E. Is the Patient able to sit in a chair or wheelchair?  YES   NO If NO, Why:
 Unable to maintain erect sitting position in a chair for time needed to transport, due to moderate muscular weakness and de-conditioning.
 Risk of falling off wheelchair or stretcher while in motion (not related to obesity).
F. Can this Patient be transported at the BLS level by an EMT Crew Only (No Paramedic on Ambulance)? YES   NO (Paramedic or higher care required)
G. If Skilled Nursing (SNF), Date of Admission:   
 
Section 3 - For Inter-Facility Transfer
 
H. Is the Patient being transfered to a higher level of care? YES   NO
     
 
I. Please list/describe facilities or procedures required/available at the destination facility not available at the originating facility:
 
J. Is the Patient being transported to the closest appropriate facility? YES   NO If No, ABN Required.
K. Is this transfer related to Patient's hospice diagnosis? YES   NO    Not Applicable

Section 4 - Additional Reasons for Ambulance Transport - Complete all that are applicable to this Patient
L. Patient's Level of Consciousness precludes other means of transport?YES   NO If YES, why:
M. Patient is hemodynamically unstable? YES   NO If YES, why:
N. Patient requires airway monitoring or suctioning?YES   NO  
O. Patient requires continuous oxygen - unable to self-administer YES   NO If YES, why:
P. Patient is ventilator dependent?YES   NO  
Q. Patient requires continuous IV therapy? YES   NO  
R. Patient requires cardiac monitoring? YES   NO  
S. Requires Isolation Precautions (VRE, MRSA, etc.)?YES   NO If YES, why:
 
T. Morbid obesity requires additional personnel/equipment to safely handle the patient:YES  NO  
U. Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport: YES   NO  
 
V. Sever Pain - Pain Scale (1-10): Explain:
 
W. Needs immobilization/positioning due to recent/potential fracture, chronic wounds, DVT, incapacitating Osteoarthritis:
          Hip  Extremity Spine  Other
X. Is the Patient: Critically Injured  Critically ill  Unstable  In Need of Immediate Intervention
Y. Altered Mental Status: New Onset  Normal Status  Status Change  As a Result of Sedation: 
Z. Decreased Level of Consciousness:  Unconscious Unresponsive  Incoherent  Lethargic  Semi-conscious, stuporous 
                                                                  Hallucinating Syncope  Seizure Prone  Intermittent consciousness 
AA. Contractures: Fetal Lower Extremity  Upper Extremity
AB. Paralysis: Paraplegic Quadraplegic  Hemiplegic
AC. Does the Patient exhibit: Violent/Combative Agitation  Delirium  Non-Compliant Hostility
AD. Requires restraints: Flight Risk  To prevent injury to self or others  To maintain upright position safely
        Type:
AE. Decubitus Ulcers: Buttocks Coccyx  Hip Other   Size:  Stage:
AF. Enter other medical condition(s) that support the medical necessity of ambulance transport:
 
 
Section 5 - Signature of Physician or Healthcare Professional
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.
If this box is checked,I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim form 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:
Enter Name of Physician* or Authorized Healthcare Professional:
 
Signature of Physician* or Authorized Healthcare Professional Enter Date of Signature:  
 
*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):
 Physican Assistant   Nurse Practitioner  Clinical Nurse Specialist   Registered Nurse
 Licensed Practical Nurse   Discharge Planner   Case Manager  Social Worker