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Physician Certification Statement (PCS) for Ambulance ...

HFS 2270 (R-7-20)Danger to Self or OthersFor Non-Emergency Transports Only Physician Certification Statement (PCS) for Ambulance TransportIMPORTANT: A patient is only eligible for Ambulance transportation if, at the time of transport, he or she is unable to travel safely in a personal vehicle, taxi, or wheelchair van. Ambulance transport requests that are for the patient's preference, or because assistance is needed at the origin or destination (to navigate stairs and/or to assist or lift the patient), and/or because another provider with the appropriate type of service is not immediately available does not meet criteria and will not be eligible for reimbursement.

Services are available at the Originating hospital, but inter-hospital transport was requested due to: 0 Patient Request 0 Insurance Requirement MEDICAL NECESSITY FOR AMBULANCE - COMPLETE ALL THAT AppLY TO PATIENT: D 1. o Is the patient "bed confined"? To be "bed confined", the patient must satisfy all three of the following conditions (check ...

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