Physician Certification Statement (PCS) for Ambulance Transport IMPORTANT: 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.

Transportation Order/Physician Certification Statement (PCS) Template to certify the need for repetitive, scheduled Non-Emergency Ambulance Transport (NEAT) Service under Medicare Part B for a Medicare beneficiary in need of such services. This template is available to the clinician and can be kept

Please complete all fields to request authorization for Non-Emergent Medical Transportation (NEMT) Services. Submit the completed form to: ModivCare* at <[email protected]> or by fax to 877-457-3352, Attn: Utilization Review.

*Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below) :

The Department of Health Care Services (DHCS) requires that a Physician Certification Statement (PCS) form be used to process and determine the appropriate level of Non-Emergency Medical Transportation (NEMT) services.

Ambulance suppliers must obtain certification from the patient’s attending physician verifying the medical necessity of ambulance transportation in certain circumstances. The physician certification must be accurate and timely as it enables billing Medicare to receive payment for ambulance services. Reviewing the patient’s program of care.

Sep 27, 2024 · Ambulance providers are required by federal regulations eCFR: 42 CFR 410.40 — Coverage of ambulance services to obtain a physician certification statement (PCS) from the attending physician for non-emergency ambulance trips (scheduled or non-scheduled) before submitting a claim to Medicare.

This form should be maintained on file with the medical record and submitted upon request to Palmetto GBA. if requested by Palmetto GBA please fax or mail this form and any supporting documentation to the address or fax number specified in …

The purpose of this form is for physicians to communicate to ModivcareTM specific transportation restrictions of a patient/member due to a medical condition. The restrictions and requirements stated on this form will be used by Modivcare

Physician Certification Statement (PCS) for Medicar/Service Car Transport. FACILITY REPRESENTATIVE - COMPLETE THIS FORM AND PROVIDE IT TO THE APPROPRIATE MEDICAR/SERVICE CAR REPRESENTATIVE IMPORTANT: A patient is only eligible for Medicar/Service Car transportation if, at the time of transport, he or she is unable to travel …