Physician certification statement 2025

1. Click ‘Get Form’ to open the physician certification statement in the editor.
2. Begin by filling out Section I – General Information. Enter the patient's name, date of birth, Medicare number, transport date, origin, and destination. Ensure accuracy as this information is crucial for processing.
3. In Section II – Medical Necessity Questionnaire, provide detailed answers regarding the patient's medical condition and transport needs. Clearly describe why ambulance transport is necessary and check applicable boxes that reflect the patient's condition.
4. Complete Section III by signing as the physician or healthcare professional. Include your printed name and credentials. If applicable, check the box indicating if you are signing on behalf of a patient who cannot sign themselves.
5. Review all sections for completeness and accuracy before saving your work. Once finalized, print and return the form as instructed.

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