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NORTH STATE <br /> REPETITIVE PATIENT ASSESSMENT FORM <br /> Section-1 Patient Information 111?DICAI,TRANSPORT <br /> Name: Sex: ❑M❑F DOB: Age: SS#: <br /> Primary Insurance: Policy Number <br /> Secondary Insurance: Policy Number <br /> Origin/Facility: Destination/Facility: <br /> Address: Address: <br /> City: State: Zip: City: State: Zip: <br /> I am requesting ambulance transportation on a repetitive basis and certify that I have consulted with my Physician and 1 can not safely be transported by any other <br /> means. I am unable to be transported by Wheelchair van,Cab or Private auto because of my medical condition. <br /> Patient's signature: Date signed: <br /> I am requesting ambulance transportation on a repetitive basis for the patient listed at the top of this form and certify that he/she cannot safely be transported by any <br /> other means. He/She is unable to be transported by Wheelchair van,Cab or Private Auto because of his/her medical condition. <br /> Signature of person requesting the ambulance transportation if patient is unable to sign: <br /> Signature: Date signed: <br /> Printed Name: Relationship: Facility: <br /> Section 2-Medical Necessity Assessment Information <br /> Describe the medical condition(physical and/or mental)of this patient that requires him or her to be transported in an ambulance and why transport by other means is <br /> contraindicated by the patient's condition. <br /> Yes/ <br /> Assessment/Questionnaire No Comments <br /> Is the patient able to go to the lunch room?If so,how? <br /> Does the patient ever leave the facility/home for family visits,shopping,etc.?If so,how? <br /> Is the patient able to get up from bed without assistance? <br /> Is the patient able to ambulate? <br /> Is the patient able to sit unassisted in a chair or a wheelchair(does not include a reclining wheelchair. <br /> Can this patient safely be transported by car,or wheelchair van(i.e.,seated during transport,without a medical <br /> attendant or monitoring)? <br /> Does this patient have contractures?Where? <br /> Does this patient have non-healed fractures?Where? <br /> Is this patient confused or likely to become confused during transport? <br /> Does this patient have moderate/severe pain on movement? <br /> Is this patient a danger to self/others? <br /> Are IV meds/fluids required during transport? <br /> Does this patient need or is likely to need restraints during transport? <br /> Does this patient have DVT requiring elevation of a lower extremity? <br /> Does this patient have a condition that requires monitoring by a medical attendant? <br /> Does this patient require oxygen and unable to self-administer? <br /> Does this patient need special handling/isolation/infection control precautions required? <br /> Is this patient unable to tolerate seated position for time needed to transport?If so why? <br /> Does this patient require hemodynamic monitoring required en-route? <br /> Is the patient unable to sit in a chair or wheelchair due to decubitus or other wounds? <br /> Provide location and approximate size? <br /> Does this patient require cardiac monitoring during transport? <br /> Is this patient morbidly obese and requires additional personnel/equipment to safely handle patient? <br /> Does this patient require orthopedic device,backboard,halo,pins,brace,wedge,etc. <br /> Requiring special handling?If so why? <br /> This document contains HIPPA information and precautions shall be taken to protect patient privacy <br /> 1240 Corporation Parkway • Raleigh, NC 27610 • 919-261-8911 • 919-261-8991 Fax • www.nsmt.biz <br />