Click here for the Ambulance PCS Form: Medical Necessity Form Version 2.0 – 2021.
Here are the guidelines for completing the PCS form:
- Section 1: Complete all of the boxes. If a hospital face sheet is provided, it is unnecessary to enter the Medicare/Medicaid #’s.
- Section 2: Provide the reason the patient needs to leave your facility and go to the destination facility. When the patient is transported to a higher level of care, check the box(es) that describes patients needs that are unavailable at your facility. If none apply, check the “Other” box and document the reason. Lastly, indicate whether the patient is being transported to the closest appropriate facility that can usually provide the care the patient requires. If you answer ‘No’, indicate in this section the reason the patient needed to go to the further facility today (i.e. what services/specialist at a closer facility wasn’t available at the time of the transport).
- Section 3 Describe the reason air ambulance was selected over ground ambulance. Check any conditions listed that apply. If none apply, check the ‘Other’ box and document the reason for air versus ground (i.e. no ground ambulance available or the local ground ambulance in unable to provide the necessary level of care).
- Section 4: Ask the attending physician to sign the form. If not available, an individual listed (Physician Assistant, Clinical Nurse Specialist, Registered Nurse, Nurse Practitioner or Discharge Planner) can sign the form.
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