Amb Necessity Form-Front Page

NOTE: This document fits on one page in Microsoft WORD/Corerel WORDPERFECT and is available upon request
AMBULANCE NON-EMERGENCY AND DIALYSIS TRANSPORTS
Certification of Medical Necessity

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