Get Lifeguard Medical Necessity Form

Filling out the Lifeguard Medical Necessity Form accurately is essential for ensuring proper medical transport. This guide provides clear, step-by-step instructions to help you complete the form online with ease and confidence.

Follow the steps to complete the Lifeguard Medical Necessity Form online.

1. Click the ‘Get Form’ button to obtain the Lifeguard Medical Necessity Form and open it in your preferred online editor.
2. Fill in the 'Miles' section at the top of the form. Ensure you provide the correct distance related to the transport needed.
3. In the 'ICD-9' section, enter the appropriate International Classification of Diseases code that corresponds to the patient’s diagnosis.
4. Complete the 'Date of Transport' field with the date the transport is requested.
5. Input the 'Point of Pickup Zip Code' to specify the location where the patient will be picked up.
6. Fill out the 'MR#' and 'Flight #' sections with the respective medical record and flight numbers, if applicable.
7. Provide the patient's full name and Social Security Number in the designated fields.
8. Complete the 'Address', 'City', 'State', and 'Zip' fields to accurately reflect the patient's location.
9. State the patient's diagnosis for air ambulance transport in the relevant field, followed by any secondary diagnosis.
10. Indicate whether the patient’s condition was critical by selecting 'Yes' or 'No.'
11. Specify if the transport was an emergency trip by choosing 'Yes' or 'No.'
12. Select whether the patient was bed confined, also using 'Yes' or 'No.'
13. If applicable, state whether the patient was transferred from one medical facility to another and provide the reason.
14. Explain the medical reasons preventing transportation by any other means, by selecting the relevant options or providing details in the space provided.
15. Obtain the authorizing signature in the designated field, and include the date of signing.
16. Complete the facility information to ensure accurate processing of the transport request.
17. Once all fields are completed, save your changes. You can download, print, or share the form as needed.

Ensure you complete the Lifeguard Medical Necessity Form online today for effective transport!