Medical Forms
Just about no one likes filling out forms, but we think finding the right form is equally frustrating. So we make it easy by providing everything you need right here.
Medical Necessity Certification
In order to receive our services, the patient’s primary care physician or nephrologist must complete this form. Both pages must be filled out in detail and all fields must be completed. The physician completing the form must sign both pages. Without a thoroughly completed Medical Necessity Certification, patients will not be transported.
Acknowlegment of Receipt of Medical Necessity form
The patient must acknowledge receipt of the Medical Necessity form, and that they have been made aware of and recognize the importance of the Medical Necessity form. This acknowledgment may signed by either the patient or the primary care provider.
Authorization to Release Medical History
This authorization form allows Care First EMS to receive the patient’s medical history. The patient’s medical history helps us understand the overall condition of the patient so that we may provide the best possible patient care. The patient or the primary care provider may sign this form.
Medicare Coverage Verification Questionnaire
The patient is required to describe their current medical condition and to provide detail as to why they require an ambulance transport on this form. This form may be filled out by the patient or the primary care provider.
Acknowlegment of Receipt of Forms
This is a receipt of the Patient Transport Packet, and must be signed by either the patient or the primary care provider.
