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
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