Transcription of Monitoring/treatment is required - Michigan Ambulance …
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Monitoring/treatment is required - Michigan Ambulance …
Agency_____ Case # (for Ambulance use)_____ P H Y S I C I A N C E R T I F I C A T I O N S T A T E M E N T (PCS) MEDICAL NECESSITY for Non-Emergency Ambulance Transportation I. 1. Transport Date: _____ 2. Origin:_____3. Floor/Unit:_____ 4. Destination: _____ 5. Physician Name: _____ 6. Phone: _____ 7. Fax: _____ Complete by explaining reason(s) why patient requires non-emergency Ambulance services. II. Patient is unable to sit or travel in a wheelchair due to: 8. _____ _____ 9. Monitoring/treatment is required during transport. (Please check off and explain in detail any of the following that would support the Ambulance transport) 10.
Section II continued: 19.These lines should be utilized to explain any of the treatment checked above or, if none of the boxes are applicable, these
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