Certification of Medical Necessity / Physician Certification Statement

PCS / CMN Forms

Select an option to complete a Physician Certification Statement or Certificate of Medical Necessity

Printable PDF

Download a blank PCS/CMN form to print and complete by hand. Ideal for facilities that prefer paper documentation.

Download PDF
Fax Completed Forms To: (716) 692-3297

Online CMN Portal

Electronically complete and submit your PCS/CMN form though our online portal. No faxing required.

Start Online Form
Helpful Hint: For completing multiple transfer forms, consider opening the online form in additional tabs.
Important Information

Completing and submitting a Physician Certification Statement, Certificate of Medical Necessity, or any other supplemental documentation does not secure your transfer request. All transfers must be scheduled through Twin City dispatch at (716) 692-2100, with all necessary prior authorizations obtained (if required) prior to transport.