Transcription of PHYSICIANS CERTIFICATION STATEMENT
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PHYSICIANS CERTIFICATION STATEMENT
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 SUNSTARP hone:Fax:Phone:(727) 587-2111(727) 582-2540 Round Trip:NoYes2)Is the patient "Bed Confined?
PHYSICIANS CERTIFICATION STATEMENT SECTION I - GENERAL INFORMATION Yes No Run #: Medicare #: Medicaid #: DOB: Fax: Patient's SSN: Is the patient's stay covered under Medicare Part A (PPS or DRG)?Yes No
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