Transport Request

TRIP ASSISTANT LINK

TRANSPORT REQUEST FORM

For external scheduling and coordination

Completed by / Facility Contact(Required)

First Last

Phone(Required)

Email(Required)

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

Minutes

AM/PM

Patient Demographics

Patient Name(Required)

First Last

DOB(Required)

SSN(Required)

Gender(Required)

Male

Female

Other

Patient Phone(Required)

Patient Address(Required)

Insurance / Payor Information

Primary Insurance(Required)

Member ID:

Secondary Insurance

Authorization #:

Payor / billing notes

Legal / Behavioral Health Status

Please click all that apply(Required)

Voluntary

Involuntary

POA

Conservator

Name/contact if POA or conservator:

Pick up and Drop-Off Information

Pickup Facility:(Required)

Unit/room:(Required)

Pickup Address(Required)

Destination Facility:(Required)

Unit/room:(Required)

Destination Address(Required)

Special pickup/drop-off instructions:(Required)

Precipitating Issue / Reason for Transport

Check all that apply:(Required)

Suicidal Ideation

Homicidal Ideation

Psychosis

Substance use/detox

Dementia

Medical Needs

Danger to self or others

Other precipitating issue / clinical summary:

PCS / MEDICAL NECESSITY DETAILS

Certificate of Medical Necessity for Ambulance Transport. In order for ambulance services to be covered, they must be medically necessary and reasonable. Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. This section captures information used to support medical necessity determinations for ambulance transportation.

Bed Confinement

Defined as patient being: (1) unable to get up from bed without assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair without assistance or restraint for duration of transport.

Bed Confinement(Required)

Patient is bed confined

Hospital to Hospital Transport / Services Not Available

Procedures not available

Equipment/procedure not available:

Description:

Specialty care services not available:

Psychiatric Unit

Intensive Care Unit

Trauma Center

Neuro

Burn Unit

Other:

Other (Description)

Medical Conditions at Time of Transport Requiring Supervision

Psych concern

Altered Mental Status

Suicidal Ideations

Psychosis

Schizophrenia

Bipolar

Dementia

Confusion

Aggressive

Combative

Flight Risk

Unconscious

Danger to self or others

Other

Other (Description):

Wound / Fracture / Contractures:

Sacral

Buttocks

Back

Hip

Other:

Stage:

Unable to sit due to stage II or higher wound:

Other (Description)

Stage (Description)

Fracture:

Hip

Pelvis

Femur

Other

Other (Descripton)

Choose:

Left

Right

Contractures:

Arms

Legs

Trunk

Other conditions / Requirements

Morbid obesity (LBS):

Obesity

Lift Assistance

Special Equipment

Paralysis:

Hemi

Para

Quad

Other Conditions:

Fall Risk

General Weakness

Reduced Mobility

Terminal Disease

Other:

Special Requirements

O2 administration

Advanced airway monitoring or suction

Ventilation dependent

Monitoring / seizure prone

Cardiac EKG / ECG monitoring

Isolation precautions

Orthopedic device to limit movement / relieve pain

Continuous supervision

Isolation type / other requirement:

Patient Unable to Sign / Certification and Signature

Unable to sign

Patient physically / mentally incapable of signing the ambulance service claim form

Specific reason patient is physically or mentally incapable of signing:

I certify that the above information is accurate based on my evaluation of this patient, and that the medical necessity provisions of 42 CFR 410.40(e)(1) are met, requiring that this patient be transported by ambulance. I understand this information will be used by CMS to support the determination of medical necessity for ambulance services. I represent that I am the beneficiary's attending physician; or an employee of the beneficiary's attending physician, or the hospital or facility where the beneficiary is being treated and from which the beneficiary is being transported; that I have personal knowledge of the beneficiary's condition at the time of transport; and that I meet all Medicare regulations and applicable State licensure laws for the credential indicated.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Printed name and credentials of physician or authorized healthcare professional:(Required)

Credential / Role:(Required)

Physician Assistant

Clinical Nurse Specialist

Licensed Practical Nurse

Case Manager

Nurse Practitioner

Registered Nurse

Social Worker

Discharge Planner

Repetitive / Scheduled Transport Note

For scheduled repetitive transport, this form is not valid for transports performed more than 60 days after the signature date. For nonrepetitive ambulance transports, if unable to obtain the signature of the attending physician, an authorized healthcare professional may sign when permitted by applicable requirements. This form is intended for transport scheduling and medical necessity documentation. Completion of this form does not guarantee insurance coverage or payment. Team Mobile Health Care may request additional documentation as needed.

Transport Request