PHYSICIANS CERTIFICATION STATEMENT

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PHYSICIANS CERTIFICATION STATEMENTSECTION I - GENERAL INFORMATIONNoYesRun #: Medicaid #: Medicare #: DOB: Fax: Patient's SSN: Is the patient's stay covered under Medicare Part A (PPS or DRG)?Yes NoMedical Record #:Destination: From: Name: Date of Service: Origin: Insurance #:Closest appropriate facility? If No, why is distant transfer required?To:PINELLAS COUNTY EMS D/B/A SUNSTARPhone:Fax:Phone:(727) 587-2111(727) 582-2540Round Trip:NoYes2)Is the patient "Bed Confined? as defined below?YesNoSECTION II - MEDICAL NECESSITY QUALIFYING DOCUMENTATIONAmbulance transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the meet this requirement, the patient must be either "BED CONFINED" or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient's condition.

PHYSICIANS CERTIFICATION STATEMENT SECTION I - GENERAL INFORMATION Yes No Run #: Medicare #: Medicaid #: DOB: Fax: Patient's SSN:

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