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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