Medical Forms

For the convenience of healthcare professionals responsible for scheduling transports on our patients’ behalf, we have the following forms available. These forms are also available in your Transportation Reference Guide. Please feel free to print as many additional copies as you would like.

Physician Certification Statement (PCS), verification of medical necessity of the transportation. Required for all non-emergency ambulance transports of patients under the care of a physician.

Signature/Claim Submission Authorization Form – Signature Form, requires signature of the beneficiary or the patient’s representative for:

• Submitting a claim
• Authorization to release of information
• Authorization to assignment of benefits
• Authorization to appeal claim

Advance Beneficiary Notice (ABN), Medicare form that is used prior to rendering service that is “not reasonable and necessary” or “non-covered”, according to Medicare.

Notice of Exclusion from Insurance Benefits (NEIB), is the same as the ABN however it is used for all other types of insurance.

EmergyCare Notice of Privacy Practices

Corry Ambulance Service Notice of Privacy Practices