Monthly Dispatch CDE Module - Finger Lakes Ambulance

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PCS and Order Forms

Purpose: This module reviews when a PCS form is required, what qualifies as an acceptable PCS, and how Transport Orders should accurately reflect the information documented on the PCS form to ensure compliance, consistency, and billing accuracy.

What Is a PCS Form?
A Physician Certification Statement (PCS) verifies that ambulance transport is medically necessary—that other forms of transportation (such as a wheelchair van or private vehicle) would endanger the patient’s health.
It provides written confirmation that the patient meets the medical-necessity criteria for ambulance transport and ensures the trip can be billed appropriately.

When is a PCS Is Required?
A PCS form is required for all non-emergency transports, including hospital discharges, interfacility transfers, and other pre-arranged transports.
The form must be completed and signed by a physician or other authorized medical professional and must include the specific reason the patient requires ambulance transport instead of another mode.

Dispatchers must ensure a valid PCS is on file prior to dispatch whenever possible.
If the PCS cannot be obtained immediately, dispatchers must still request the forms be sent, document all attempts, to get the paperwork, in the CAD.

Handling STAT Calls
For STAT transports, dispatchers should still request a PCS form from the sending facility at the time of the call whenever possible.
If the facility cannot complete the form before the crew departs, the dispatcher should clearly document in CAD that the PCS was requested and who was contacted. The dispatcher should also follow up with the facility to obtain the completed PCS as soon as possible after the transport.
Please ensure all communication attempts are logged for QA and billing reference.
Even when the call is urgent, attempting to obtain the PCS remains a required part of the process and must be pursued and documented.

Dispatcher Responsibilities
Confirm that a valid, signed, and dated PCS is on file for every non-emergency transport.
Verify the form includes an appropriate diagnosis or condition supporting medical necessity.
Accurately document the status of the PCS in CAD to reflect whether it is on file, needs corrections, or requested.
Communicate with the facility to ensure timely completion of all missing or incomplete forms.
Notify a supervisor when issues arise or if a PCS cannot be obtained after reasonable follow-up.

What Makes a PCS Acceptable?
Each PCS form must be carefully reviewed to ensure that all required fields are completed accurately and in full.

The Date of Service must match the exact date the transport begins.

The One Way or Round Trip field must be clearly indicated—“One Way” is used for transfers when the patient will not return to the sending facility, while “Round Trip” applies when the patient will return to the original facility. 
Both the Origin and Destination must include the full facility name (if applicable) and a complete address with zip code.

The question regarding the Nearest Appropriate Facility must also be answered “Yes” or “No.” If “No” is selected, the form must include a clear and specific explanation of why the patient was not transported to the nearest appropriate facility.

Section 1 - Is the Patient "Bed Confined" as described above? Must be checked Yes or No. 
Bed confined means the patient is unable to get up without assistance, unable to ambulate, and unable to sit in a chair or wheelchair.

Section 2 -  Can this patient be safely transported by car or wheelchair van?
This must be checked Yes or No.
If "No" this supports the need for ambulance transport.

if "Yes," dispatchers should request clarification from the facility.

Section 3 -  “What physical or medical condition does the patient above present with on the date of ambulance transportation that required the patient to be transported on a stretcher or in an ambulance?”
Must describe the underlying medical condition or diagnosis that explains why ambulance transport and the supports listed in Section 4 are necessary.
Should not simply repeat what is checked in Section 4 (e.g., “requires oxygen”).
Typically the patient's diagnosis will be written in, however if left blank, it must go back to the facility to be corrected.

Section 4 - Additional Information
Medical Attendant Required must always be checked.
Based on the information provided by the caller during call intake, the dispatcher must ensure that all corresponding and applicable boxes on the PCS are checked.

Signature: Must be signed by the healthcare professional initiating or authorizing the transfer.
Printed Name: Must be legible.

Bottom of Form: If signed by anyone other than a physician, the level of care for the signer (e.g., RN, PA, NP) must be circled.

Transport Order Form
The Transport Orders Form is completed by the sending facility and outlines what the patient will require during transport. It must be signed and dated by an appropriate healthcare professional to be accepted. The information documented on the Transport Orders must match what is written on the PCS, ensuring both forms consistently reflect the patient’s needs and the medical necessity for ambulance transport.

Why Does It Matter? 
Accurate PCS handling ensures we remain compliant with Medicare and Medicaid regulations. Ensures we are able to utilize our resources to the best of our ability. 
Provides consistent professional standards across the Communications Department.

Next Step: 
Review the provided scenarios and sample forms, and determine if you believe the forms to be acceptable or not. If not, briefly describe what corrections, should be made.

Geneva General ED calling for a BLS transport to Strong ED. 69-year-old male, post-op infection. No specials, vitals every 20 mins. Is the paperwork acceptable? If no, please explain why.(Required)

🔗 View Sample Forms 1

Geneva General ED calling for a BLS take home to the Huntington Living Center. 86-year-old male with dementia. Is the paperwork acceptable? If no, please explain why.(Required)

🔗 View Sample Forms 2

Clifton Springs ED calling for an ALS transfer to RGH ED. 32-year-old male N-Stemi. Cardiac Monitor, Heparin running and 02. Is the paperwork acceptable? If no, please explain why.(Required)

🔗 View Sample Forms 3

Newark Wayne 2 West calling for a round trip BLS transfer to Clifton Springs IR. 65-year-old male needing a peg tube placement. No specials. Is the paperwork acceptable? If no, please explain why.(Required)

🔗 View Sample Forms 4

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