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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.

Ambulance transport requests that are for the patienfs preference, ... prior to and during transport, and is expected to require the treatment after transport. ... Ona transport authorization. dete: 0 Round trip transport authorization (pick up and drop 011), date: ...

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