AMBULANCE MEDICAL NECESSITY FORM
|RECIPIENT INFORMATION |
|Recipient Name: |Medicaid/Insurance ID #: |DOB: ____/____/____ |
|Dispatch Date(s): |Start Date: _____/_____/_____ End Date: _____/_____/_____ |
| |For scheduled routine appointments, use the dates indicated on the Authorization Request Form (Form 272AMB) |
|Locations: |Transported From: Taken To: |
|AMBULANCE PROVIDER INFORMATION |
|Provider Name: |Provider Medicaid #: |
|MEDICAL NECESSITY FOR AMBULANCE TRANSPORTATION |
|Was the recipient ambulatory? |( YES ( NO |
|Could other means of transportation have been used without endangering the patient’s condition? |( YES ( NO |
|Is the Recipient “Bed Confined”? ( YES ( NO |
|Must meet all three conditions: (1) unable to get up from bed without assistance; and (2) unable to ambulate; and (3) unable to sit in a chair or wheelchair. |
|The physical/mental condition that necessitates transport by ambulance and why other means of transport is contraindicated: |
| |
| |
|If applicable, the reason patient was transferred from one institution to another: |
|AMBULANCE SERVICES PROVIDED |
|Check appropriate box: ( BLS ( ALS (provide details below) |
|Suspected diagnosis or presenting symptoms: (complete only when ALS services are provided) |
|( Chest pain ( Respiratory Arrest ( Respiratory Distress ( Dizziness or Syncope ( Unconscious |
|( Burns ( Shock ( Seizures ( OD/Poison |
|( Other (Describe): _____________________________________________________________________________________________ |
|ALS Care Provided: (complete only when ALS services are provided) |
|( Placement Extrication ( Endotracheal Tube Placement ( EKG (circle one): Monitor / Telemetry |
|( CPR ( Defibrillation ( I.V. Therapy |
|SCHEDULED AND ROUTINE AMBULANCE TRANSPORTATION (If applicable) |
|Reason for the Transport: ( Medical Appointment ( X-rays ( Chemotherapy/Radiation Treatment ( Diagnostic Lab Services |
|( Dialysis ( Other (describe:)_________________________________________________________________ |
|MEDICAL CERTIFICATION FOR AMBULANCE TRANSPORTATION |
|I certify that I have personal knowledge of the recipient’s condition. I further certify that the above information is true and correct based on my evaluation, |
|and represents that the recipient requires transport by ambulance. I understand that this information will be used to support the determination of medical |
|necessity and payment for ambulance services by the NH Medicaid program. |
| | |
|___________________________________________________ |(MD (DO (PA (CNS (APRN (RN (LPN (Discharge Planner |
|Signature of Healthcare Provider |Healthcare Provider Credentials |
| | |
|___________________________________________________ |_____________________ |
|Printed Name of Healthcare Provider |Date Signed |
|Signature must be provided by one of the following: Attending Physician (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Clinical Nurse Specialist |
|(CNS), Advanced Practice Registered Nurse (APRN), Registered Nurse (RN), License Practical Nurse (LPN), or a Discharge Planner employed by the facility where |
|the recipient is being treated. |
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272-MN
11/12
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