Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to acquire the form and open it for online completion.
2. In Section I, fill out the patient's name, date of birth, and Medicare number. Include the transport date and specify the origin and destination of the transport.
3. Indicate whether the patient's stay is covered under Medicare Part A by selecting ‘YES’ or ‘NO’. Further, confirm if the closest appropriate facility is being utilized. If not, provide an explanation for choosing a more distant facility.
4. If the patient is being transferred from one hospital to another, detail the services required at the second facility that are unavailable at the first. If the patient is in hospice, indicate whether the transport is related to the terminal illness.
5. Proceed to Section II and answer the necessary medical necessity questions regarding the patient's condition and transport requirements. Describe in detail why the patient needs ambulance transport and why alternative means are contraindicated.
6. Check ‘YES’ or ‘NO’ to indicate if the patient is 'bed confined,' ensuring all criteria are met for this designation.
7. In this section, identify any other applicable conditions that might require ambulance transport. Maintain supporting documentation if you check any boxes.
8. Finally, proceed to Section III to have the physician or healthcare professional certify the information provided. Ensure that this is signed and dated by the appropriate healthcare personnel, including any credentials they may have.
9. Once all sections are completed, save your changes, and consider downloading or printing the form for your records.

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