2016-698 Emergency Svc - North State Medical Transport - Application for Services Franchise by Ordinance

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ORTH STATE Physician Certification Statement (PCS) Phone: 919-261-8911 .MEDICAL TRANSPORT Required for all Non-Emergency Ambulance Transports Or Toll Free 877-261-8911 Fax 919-261-8991 Section 1 - Patient and Transport Information Patient Name: Date of Birth: SSN: Sex: Medicare Number: ❑M OF Date of Transport: Time: Round Trip: Type: Transport Agency; Medicaid Number: North State Medical Transport ❑ Yes ❑ No ❑ ALS❑ BLS Transport From: Room/Bed Transport To: Room/Bed Ins. Type/Policy Number: Section 2 Medical Necessity Information YOU MUST COMPLETE ALL STEPS IN ORDER FOR THIS FORM TO BE VALID Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement,the patient must be either"bed confined"or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient's condition.The following steps must be completed by the medical professional signing in Section 3 for this form to be valid. Step 1—Are ALL of the following true for this patient? Step 2—Can this patient safely be transported by car or wheelchair van? l-Patient is unable to get up from bed without assistance; (i.e.,seated during transport,without medical attendant or monitoring) 2- Patient is unable to ambulate; and 3- Patient is unable to sit in a chair, including a wheelchair ❑ Yes ❑No ❑ Yes ❑No If No,use Step 3 to identify reasons for transport. "A.NO'does not automatically indicate the transport will notbecovered. If Yes,transport is not medically necessary. Step 3—Check all that apply to the patient at the time of transport ❑ Requires Continuous Oxygen ❑Assistance required to apply, administer,regulate, or adjust oxygen in route ❑ Requires airway maintenance ❑ Ventilator dependent ❑ Requires cardiac/hemodynamic monitoring ❑ Moderate/severe pain on movement ❑ Requires IV meds/Fluid Maintenance ❑ DVT requires elevation of a lower extremity ❑Non-healed fractures ❑ Requires immobilization of fracture or possible fracture ❑ Contractures ❑ Requires orthopedic device(backboard, halo, use of pins in traction,etc.) ❑ Danger to self/others ❑ Requires monitoring because patient is confused or combative ❑Altered mental status ❑ Requires monitoring due to a decreased level of consciousness or lethargy ❑ Comatose and requires monitoring ❑ Restraints(chemical or physical)required or anticipated during transport ❑ Requires Monitoring due to seizures Morbid obesity ❑ Unable to maintain erect sitting position in a chair for duration of transport Special handling/Isolation Precaution ❑ Unable to sit in a chair/wheelchair due to decubitus ulcer or other wounds Facility to Facility Transfer: ❑No bed available OTHER(specify) ❑ Services not available at originating facility ❑ Transport to nearest appropriate facility *Supporting documentation for any boxes checked must be maintained in the patient's medical record* Section 3 - Authorization and Signature I certify that the above information is true and correct based on my evaluation of this patient,and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated.I understand that this information will be used by the Centers for Medicare and Medicaid.Services(CMS)to support the determination of medical necessity for ambulance services,and I represent that I have personal knowledge of the patient's condition at the time of transport. ki Step 1 Print the name of the individual who will sign this form Step 2 Choose credentials corresponding to the name in Step I ❑Physician ❑ Registered Nurse ❑ Nurse Practitioner ❑ Discharge Planner ❑Clinical Nurse Specialist PRINTED Name of Physician or Medical Staff *Per CMS,these individuals are the only ones authorized to complete the PCS form. Step 3 Sign in ONE of the designated boxes.(Physicians in the left box,all others in the box on the right) Physician Signature: Medical Staff Signature: (Only valid for a single transport) Physician's Signature Credentials Date Medical Staff Signature Credentials Date 55