Get Umc Physician's Certification Statement 2005-2025

This guide provides clear instructions for completing the UMC Physician's Certification Statement to certify the medical necessity of non-emergency ambulance transportation. Follow these steps to ensure your submission is accurate and efficient.

Follow the steps to complete the certification statement

1. Press the ‘Get Form’ button to access the UMC Physician's Certification Statement and open it in your selected editor.
2. Enter the patient's name in the designated field at the top of the form.
3. Fill in the medical record number associated with the patient.
4. Indicate the transport origin and destination by filling in the 'Transport From' and 'Transport To' fields.
5. Review the checklist provided in the form. Mark all applicable boxes that describe the patient's condition and need for ambulance transportation.
6. Provide additional information in the narrative section to give context to the medical situation as necessary.
7. In the certification statement section, ensure to include the printed name of the physician certifying the information.
8. Sign and date the form, making sure to include the title of the authorized person, such as M.D., P.A., or R.N.
9. Once completed, you can save any changes made to the form, and download, print, or share the document as needed.

Complete your UMC Physician's Certification Statement online today.