Please Complete the Following Fields with Specific Details
Transportation from:
Transportation to:
Transport service:
Please complete the following fields with specific details.
In my professional opinion, this patient requires transport by ambulance and should not be transported by other means for the reasons listed below:Criterion 1: Patient is confined to bed as defined by the following:
Unable to get up from bed without assistance, AND
Unable to ambulate, AND
Unable to sit in a chair or wheelchair.
OR
Criterion 2: The patient does not meet the criteria for bed confinement, but there are medical issues that preclude the use of other means of transportation (e.g. wheelchair van), as noted below:Patient is comatose, semi-conscious, or unresponsive.
Patient is unable to tolerate or maintain erect sitting position for the time needed to transport (e.g. severe contractures, quadriplegia, recent spinal surgery, unhealed or unstable fracture of the pelvis, hip or femur).
Wound precautions are required,due to decubitus ulcers (or other wounds) of the sacrum, buttocks or hip.
Patient is considered adanger to themselves and/or others (e.g. suicidal or psychotic,need for restraints or an attendant for safety).
Patient is in the end-of-life stage of a terminal condition (e.g. transport to inpatient hospice).
Is transport related to patient’s terminal illness?
No Yes (describe): ______/ Continuous IV fluids or medication therapy is actively required during transportation.
Hemodynamic, cardiac, and/or airway monitoring is required during transportation.
Level of service required:
ACLS
Critical care
BLS
The patient has orthopedic devices (e.g. halo, pins, traction, wedge, etc.),which require special handling and prone positioning by the member during transport.
Facility transport and alternate transportation is not available within a reasonable time frame (e.g. after hours).
I certify that the above information is true and correct, based on my evaluation of this patient, and represent that the patient requires transport by ambulance, and that other forms of transport are contraindicated. I understand that this information will be used by Physicians Plus Insurance Corporation to support the determination of medical necessity for non-emergent ambulance transport services and I represent that I have personal knowledge of the patient's condition at the time of transport.
Signature of Certifying Healthcare Professional: ______Date: ______
Printed Name of Certifying Healthcare Professional: ______
Title (check one): MD or DO Nurse Practitioner Physician Assistant
Form must be signed only by patient's attending physician or supervised mid-level provider (e.g. PA, NP).
P+6892-1801