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Click ‘Get Form’ to open the certification statement sample in the editor.
Begin by filling out SECTION I – GENERAL INFORMATION. Enter the patient's name, date of birth, transport date, and insurance number. Specify the origin and destination of the transport.
Indicate whether the patient's stay is covered under Medicare Part A by selecting 'YES' or 'NO'. If 'NO', provide a brief explanation for why transport to a more distant facility is required.
In SECTION II – MEDICAL NECESSITY QUESTIONNAIRE, answer all questions regarding the patient's medical condition and transport needs. Ensure that you describe why ambulance transport is necessary and check applicable conditions.
Finally, complete SECTION III by having the physician or healthcare professional sign and date the form. Ensure that their printed name and credentials are included for validation.

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