County of Volusia, Patient Name: Florida. EVAC Ambulance

County of Volusia,

Florida.

EVAC Ambulance

112 Carswell Av Holly Hill, FL 32117

(386) 252-4900 (800) 323-3822

Patient Name: ____________________________

PHYSICIAN'S CERTIFICATION STATEMENT FOR AMBULANCE TRANSPORTION

Today's Date: Current Time:

____/____/______ ____: _____ AM PM

Transport

One-Way

Round Trip

Date of Transport _____/_____/_____

Requested Time of Transfer ____:____ AM PM

Origin/Pickup:

__________________________

Destination

__________________________

Address:

__________________________

Address:

__________________________

__________________________

__________________________

Phone #: ___________ Tran. Physician: _____________

Phone #: ___________ Recv. Physician: ____________

1. CERTIFICATION

I certify that ambulance transport of this patient is medically necessity due to the following:

1a Patient is Bed Confined

Yes No

Bed confined is defined as unable to get up from bed without assistance, unable to ambulate, or unable to

sit in a chair or wheelchair (does not include orders for bed rest). Cannot be used as a sole determination of

medical necessity

1b Does the patient's medical condition meet the definition of "Emergency Medical Condition" as defined under

Yes No

Florida Statutes 395.002(9)? If yes, please include a copy of your internal certification required under F.S.

395.1041(3)(c)2

1c Please explain in the space provided why the patient could not be transported by any other means without endangering the patient's

health (no diagnosis).

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

2. SERVICES REQUIRED IN THE BACK OF THE AMBULANCE

(This constitutes the equivalent of a physician's order)

2a The patient requires the following services that would contradict the transport of the patient by any other means other than an

ambulance.

Cardiac Monitor and IV Fluids

IV Fluids Only

Medications (IV, IM, SQ)

Cardiac Monitor and Saline Lock

Suctioning/Advance Airway

Mechanical Ventilation

Management

Other: ___________________________________________________________________________________

3. SPECIALITY REQUIRED AT THE DESTINATION FACILITY THAT IS NOT AVAILABLE AT ORIGINATING FACILITY The patient requires one or more of the following services which are not available at the original facility. Please note, verification of availability of these services at both original and destination facility, unless "No Beds", "No Physician Available" OR "Equipment Failure" is checked in section 4, will be against the ACHA 3130-8008 ("Inventory of Services") completed by the hospital and on file with the State of Florida, JCAHO or current letter of services available provided to the ambulance provider.

Burn Center Services Endocrinology Gynecology Internal Medicine Neurology Obstetrics Ortho Rehab Services Pediatric Cardiology Pediatrics Hematology Plastic Surgery Thoracic Surgery Transplant Services - Lung

Urology

Cardiology Gastroenterology Hand Surgery Interventional Radiology NICU Level 3 Oncology Spinal Cord Rehab Pediatric Pulmonology Pediatrics Neurosurgery Podiatry Stroke Rehab Transplant Services - Liver

Vascular Surgery

Cardiovascular Surgery General Surgery Hematology Nephrology NICU Level 2 Ophthalmology Orthopedics Pediatric Urology Pediatrics Nephrology Pulmonary Medicine Transplant Services - Heart Trauma Center Level 1

Ventilation Rehab Services

Colon & Rectal Surgery Geriatrics Hyperbaric Medicine Neurosurgery NICU Level I Oral/Maxillo-Facial Surgery Otolaryngology (ENT) Pediatrics (General) Pediatrics Surgery Radiology Transplant Services - Kidney Trauma Center Level 2

Investigative or Experimental Service or Procedure.

PHYSICIAN'S CERTIFICATION STATEMENT FOR AMBULANCE TRANSPORTION (Page 2)

4. SPECIFIC PROCEDURE NOT AVAILABLE AT ORIGINAL FACILITY

If your facility has one of the above specialties available as noted in ACAH 3130-8008, JCAHO, or correspondence previously provided to the ambulance provider, you must specify what specific procedure or service that the patient requires that is not available at your facility. Please include ICD-9-CM code, if appropriate, so as to reduce confusion. For example, if your facility has Cardiology but does not offer a specific surgical procedure such as Advanced EPS Studies, please check "Other" and enter "Advanced EPS Studies." (Please, no diagnosis)

No Beds Available Continuity of Care

No ICU Beds Available Family Preference

No Physician Available Contract

Equipment Failure

Other: ________________________________________________________________________________________________________

________________________________________________________________________________________________________________

5. CLOSEST FACILITY I certify that each of the facilities listed below were either contacted and could not accept the patient because of the reason identified or the facility does not offer the services that the patient requires as verified via ACHA 3130-8008 ("Inventory of Services"). Unless noted in Section 4, above, I also certify that the patient is not being taken to the destination facility for the purpose of continuity of care, for patient or physician preference, or under contracted arrangements between the originating facility and the destination facility.

FACILITY

Florida Hospital ? Flagler Florida Hospital ? Memorial Halifax Medical Center ? Daytona Halifax Medical Center ? Port Orange Bert Fish Medical Center Florida Hospital ? DeLand Florida Hospital-Fish Memorial Central Florida Regional Hospital Florida Hospital ? Orlando Florida Hospital ? Altamonte Orlando Regional Medical Center Arnold Palmer/Winnie Palmer Children's Hospital South Seminole Hospital Select Specialty Hospital Orlando South Select Specialty Hospital Orlando Winter Park Memorial Hospital Shands Hospital - Gainesville Baptist Medical Center (JAX) Brooks Rehab Hospital Mayo Clinic (JAX) Memorial Hospital Jacksonville St. Vincent's Medical Center (JAX) Shands Hospital - Jacksonville St Luke's Hospital

Services Not

Available

No Beds

On-Call Physician at destination facility refused to accept patient because patient not under his/her

care.

I certify that the above statements are true and accurate to the best of my knowledge and that I understand and acknowledge that under 31 USC Section 3729-3733, whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry may be subject to civil or criminal actions by the U.S. Department of Health and Human Service, Center for Medicare and Medicaid Services, or the U.S. Department of Justice and may be subject to civil or criminal penalties or exclusion from State or Federal Programs.

___________________________

___________________________________

Printed Name of Physician

Physician's NPI

Signature of Physician

If the physician is unavailable, this form may be completed by an RN, CNS or PA, below.

_____________ Date

__________________________________ Printed Name and Credentials

__________________________________ Signature of RN, CNS or PA

_____________ Date

This document will become a part of the patient's permanent patient care report and made available to the Center for Medicare and Medicaid Services or the Florida Agency for Health Care Administration in the event of an audit, appeal or other investigation conducted by a state or federal agency.

Revised: 06-2016

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download