Scheduled Appointment For:

Radiation Tx Dialysis Tx MRI Scan CT Scan Endoscopy Angiography Out-Patient / Ambulatory Surgery Caridac Catheterization
Lymphatic / Venous Procedures Wound Care Other:

Physicians Certification Statement - Required by 42 CFR 410.40 (D) for all Non-Emergent transports.

In my professional opinion, this patient's medical condition requires transport by Ambulance and the level of care that implies and other means of transport are contraindicated based on the patient's health and safety.

Patient Bed Confined and is Unable to get up or out of bed without assistance AND Unable to ambulate AND Unable to sit in a Wheel chair or chair because:

Note: The term applies to individuals who are unable to tolerate any activity out of bed. This term is not synonymous with "Bed Rest", or "Non-Ambulatory", or "Stretcher Bound". All three components must be met in order for the patient to meet the requirements of the definition of "Bed Confined".

Requires an Ambulance because:

Unable to hold self in w/c due to:
Bilateral AKA AKA and opposite BKA
Unable to sit for duration of transport due to:

Decubitus Ulcer of: Sacrum Buttocks Coccyx Hip Lower Extremity Other:

Overall Wasting, too weak to sit up due to:

Paralysis: Hemi Semi Quadriplegic

Fracture of: Neck Spine Hip Leg Knee
Other Fracture:

Contractures or Abnormal Stiffness or Rigidity of:
Upper R/L Lower R/L Extremities
Severe Pain due to:

Psychiatric Issues: Danger to Self Danger to Others Flight Risk
Chemical or Physical Restraints

Patient Requires Medical Monitoring:

Airway / Suctioning
Ventilator Dependent
Seizure Precautions
IV / Rx Infusion
Cardiac Monitoring
Unable to self-administer Oxygen needed
Comatose / LOC

Isolation due to:

MRSA VRE C-DIFF TB Meningitis Other:

Other (Describe what or why):

I certify the above information is true and correct based on my evaluation of this patient. I understand that the information herin shall be used by the Department of Health and Human Services to support the determination of Medical Necessity for Ambulance transportation. This does not guarantee or assure payment shall be made for services rendered to your patient.

Physician or Designee Name (print): MD PA RN SW DP

Physician or Designee Signature:

Date:

Senior Care Emergency Medical Services Inc EMT Name: