Nhrmc certification 2026

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The document is a Physician Certification Statement for Medical Transport, which outlines the requirements and procedures for non-emergency ambulance transport. It includes sections for general patient information, a medical necessity questionnaire to determine if ambulance transport is required, and a signature section for healthcare professionals to certify the patient's need for transport. The document emphasizes the criteria that must be met for medical necessity, including bed confinement and specific medical conditions, and provides guidelines for completing the form accurately.

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In SECTION I, enter the patient's name, date of birth, and medical record number. Specify if this is a return to prior arrangement or a new placement, and fill in the initial transport date along with the expiration date for repetitive transport.
For SECTION II, answer whether the patient is bed confined by checking 'Yes' or 'No'. Provide a detailed description of the patient's medical condition that necessitates ambulance transport and why other methods are unsuitable.
Indicate if the patient can be transported in a wheelchair van. Check all applicable conditions that apply to support the need for ambulance transport.
In SECTION III, ensure that a physician or healthcare professional signs and dates the form. If signed by an RN, include a physician's order specifying ambulance transport.

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