ATTACHMENT A
Physician Certification Statement (PCS)
For Non-Emergency Ambulance Transportation

 For Non-Emergency Ambulance Transportation
Effective February 24, 1999 (with a grace period until August 29, 1999), Medicare requires via 42 CFR Part 410.40(d) that ambulance providers obtain a Physician Certification Statement (PCS) signed by the patient's physician, PA, NP, CNS, RN or discharge planner, for the provision of non-emergency ambulance transportation. Please complete all sections of this form and have the patient's physician, PA, NP, CNS, RN, or discharge planner, sign the form. (2/22/2000)
Section 1 - Beneficiary Information
Name: Date of
Certification:
Sex:  M __ F __ DOB: Age: Patient’s SSN:
Medicare No. Part B? __ Yes __ No Medicaid No:
 Section 2 - Medical Necessity Information (to be completed by physician, PA, NP, CNS, RN, or discharge planner) (02/22/2000)
  • Medicare covers ambulance services only if they are furnished to a beneficiary whose medical condition is such that other means of transportation would be contraindicated (i.e., normal transportation would endanger the health of the patient).
  • For non-emergency transportation, the following criteria must be met to ensure that ambulance transportation is medically necessary. The following criteria must be applicable to the condition of the patient at the time ambulance services are provided:

(i) the beneficiary is unable to get up from bed without assistance;

(ii) the beneficiary is unable to ambulate; and

(iii) the beneficiary is unable to sit in a chair or wheelchair.

  • Medicare covers non-emergency, scheduled ambulance services if the ambulance supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying the medical necessity requirements above are met. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.
  • Medicare covers non-emergency, unscheduled ambulance services under the following circumstances:

(i) for a resident of a facility who is under the care of a physician if ambulance supplier obtains a written order from the beneficiary’s attending physician within 48 hours after the transport, certifying the medical necessity requirements above are met.

(ii) for a beneficiary residing at home or in a facility who is not under the direct care of a physician, a physician certification is not required.
Does the beneficiary’s condition meet Medicare’s definition of medical necessity?  __Yes __No
Describe the beneficiary’s physical condition(s) and/or medical interventions that makes transportation by ambulance medically necessary (i.e., normal transportation would endanger the health of the patient) and describe the patient’s current general physical condition:
Print the name of the physician ordering
ambulance transportation:		 UPIN:
Physician’s signature: __________________________________________ Date: _____________

I certify that the above information represents an accurate assessment of the patient’s medical condition(s) and that in my professional medical opinion, this patient requires transport by an ambulance and should not be transported by any other means. I understand that this information will be used by the Health Care Financing Administration to support the determination of medical necessity for non-emergency ambulance services.