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.t%%STCfIOICw, <br /> 1LlblfLl,TRANSVOS6 <br /> 800-380-7909 <br /> "Our 91 Priority it Ponrnr Cana" 123 Summer Lakes Drive,Cary,NC 27513 <br /> PHONE:(919)454-4652 <br /> FAX: (800)380-7909 Transport Type: Ambulance BLS <br /> TRANSPORT REQUEST FORM Please call Ahead to schedule & confirm your request <br /> Transport Date: Requestor: Phone: <br /> Patient Name: SSN: DOB: <br /> Medicare#: Medicaid #: <br /> Other Insurance Name: Policy#: <br /> Ambulance 1. Does this patient occupy a Medicare Bed? Yes or No <br /> Transport <br /> Only 2. Is this transport related to the Patient's Plan of Care? Yes or No <br /> 3.Transport paid by: Medicare Medicaid Facility Private Other <br /> Pickup Time: AM/PM Appointment Time: AM/PM <br /> Pickup Location: Room#: <br /> Receiving Location Address: Suite#: <br /> Receiving Doctor's Name: Phone#: <br /> Reason for Transport/Patients Diagnosis: <br /> Special Instructions: <br /> Approximate weight of patient: lbs. Oxygen Required? Yes or No If yes, LPM <br /> Will this Patient need to be returned? Yes or No Return time: AM/PM <br /> Does this Patient require an escort? Yes or No Escort Type: Staff Ride Along Family to Meet <br /> Family Member Name: Phone#: <br /> A valid Certificate of Medical Necessity is required by Medicare/Medicaid for ambulance transports. <br /> PRIOR TO FAXING TRANSPORT REQUEST FORM,CALL THE SCHEDULING OFFICE AT 800-380-7909 OR(919)454-4652 TO <br /> VERIFY AND CONFIRM AVAILABILITY FOR THE REQUESTED TRANSPORT DATE/TIME. VERBAL CONFIRMATIONS ARE REQUIRED <br /> TO GUARANTEE TRANSPORT. REQUESTS FAXED PRIOR TO CONFIRMING ARE NOT GUARANTEED. <br /> FCMT Use Only: Received/entered by Date: <br />