Kentucky Medicaid requires this physician certification statement to show that a non-emergency ambulance transport is medically necessary because other transport is contraindicated. The signer describes the patient's condition at the time of transport, answers whether the patient is bed confined and checks qualifying conditions. The ambulance provider keeps it with its claim.
The physician or authorized healthcare professional completes Sections II and III and signs; Section I covers patient, transport and facility details. Only the attending physician may sign for scheduled repetitive transports.
Download the current version from the source each time; forms change without notice.
Kentucky Physician Certification Statement of Medical Necessity for Non-Emergency Ambulance Services
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For scheduled repetitive transports, only the patient's attending physician. For non-repetitive transports, if the attending physician's signature cannot be obtained, a physician assistant, nurse practitioner, clinical nurse specialist, registered nurse, licensed practical nurse, case manager, social worker or discharge planner may sign, checking their credential.
For a single transport, it covers round trips on the transport date entered in Section I. For scheduled repetitive transports, the form is not valid for transports performed more than 60 days after the date it was signed, so a new statement is needed after that.
The signer certifies that the medical necessity provisions of 42 CFR 410.40(e)(1) are met. An optional box lets the signer also certify, under 42 CFR 424.36(b)(4), that the patient cannot sign the ambulance claim form, giving the reason required by 42 CFR 424.37.