Transport Order Form

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 either be bed confined or suffer from a condition such that transport by ambulance is medically required. To be bed confined, the patient must meet ALL the following criteria:

I certify that the above information is true and correct based on my evaluation of this patient, the best of my knowledge and professional training, and that this patient requires ambulance transport. I understand that this information will be used by the Department of Health and Human Services and the Centers for Medicare and Medicaid Services to support the determination of medical necessity for ambulance services.

This must be completed for all (SCT, ALS, & BLS) patients needing transport from your facility.

2) Airway Management / Oxygen

3) Airway Management / Oxygen

4) Cardiac Monitor

5) IV Therapy

6) IV Medication Drips

7) PRN Medications

8) Arrhythmia Management

9) NG/OG Maintenance

10) Chest Tube Maintenance

11) Neurological Checks

12) Restraints

13) Other Orders

14) Contact Info: IMPORTANT, this transport order will either be accepted or denied - please wait for a follow up email from our team to notify you of your transport order status. The email supplied below will be used to contact you.