PCS / CMN Form | Twin City Ambulance

Patient & Trip Information

Patient Demographics

First Name *

Last Name *

Date of Birth *

/ /

SSN

MRN / Facility ID

At least one identifier (SSN or MRN) required.

Insurance Optional

Trip Details

Service Date *

Same Day Round Trip *

Yes

No

Closest Appropriate Facility *

Yes

No

📍 Pick Up Location

Facility Name *

Address *

Room *

Dept/Unit *

Quick Picks

🏁 Drop Off Location

Facility Name *

Address *

Room *

Dept/Unit *

Quick Picks

Transport Reason *

Diagnostic Test

Procedure/Treatment

Specialty Care

Surgery/Consult

Obs./Admit

Services N/A

Palliative/EOL

Discharge

Discharge To *

Specialty Category (Opt)

Trauma

Cardiac

Neuro

Ortho

Psych

Maternity

Pediatrics

Cancer

ESRD/Dialysis

Medical Condition

Medical Condition Criteria: The patient's current medical condition (physical or mental) AT THE TIME OF TRANSPORT that requires certified EMS personnel to medically monitor, treat, observe, and/or handle the patient and transport by ambulance. All other means being unsafe or contraindicated.

Important: These are NOT "risk for" conditions related to the patient's history. This is the actual, current condition the patient is experiencing. Death does not count as a valid condition.

Condition *

125

Medical Necessity

Bed Confinement Status

CMS Bed Confinement Criteria: Is the patient bed confined by ALL THREE of the following CMS criteria:
1) Unable to get up from bed without assistance; AND
2) Unable to sit up in a chair or wheelchair; AND
3) Unable to ambulate

Patient is Bed Confined *

Yes — Patient meets all three criteria

No — Patient does NOT meet one or more criteria

No — but Physician ordered supine, semi-fowlers, or immobile

Justification *

125

Mental Status

Glasgow Coma Scale Level *

NormalGCS 15

Mildly DiminishedGCS 13-14

Moderately DiminishedGCS 9-12

Severely DiminishedGCS 3-8

Altered Mental Status is due to: *

Chronic Baseline

Decreasing Chronic Baseline

Emergent / Acute Change(s)

Sedated

Additional Mental Status Modifiers? (Select all that apply)

Not Applicable

Dementia

Confusion

Comatose

Impaired by Drugs or Alcohol

Psychological Crisis

Medical Care Required

Additional Medical Care or Monitoring *

Not Applicable

Cardiac Monitoring

Airway Management

Oxygen RequiredUnable to self-administer

IV with or without Fluids

Medication Infusion via Pump

BiPAP or CPAP

Suctioning

Pain Management

Transport Ventilator

Post Cardiac Arrest Care

Physical or Chemical Restraint(s)

Monitoring of Abnormal Vital Signs

Specific Devices or MedicationsExplain below

BiPAP

CPAP

Own Ventilator

EMS Ventilator

Special Handling Requirements

Special Handling Procedures or Concerns *

Not Applicable

Fall Risk

Flight Risk

Combative

Lacks Trunk Control or Strength

Lower Extremity Amputee

Non-Weight Bearing

Danger to Self or Others

Fragile / Weak

Moderate to Severe Pain on Movement

Contracture(s)

Decubitus Ulcers

Fractures / Dislocations

Infection(s) or Isolation Control

Limb Elevation

Morbid ObesityEnter weight below

Mechanical Lift or 2+ AssistHoyer, Stand-Lift, etc.

Other, Not ListedExplain below

Physician Certification

I certify that the above is accurate based on my evaluation of this patient, and personal knowledge of the patient's condition at time of transport, which meets the medical necessity provisions of 42 CFR 410.40(e)(1), requiring transportation by ambulance. I understand this information will be used by the Centers for Medicare & Medicaid Services (CMS) and/or other insurances to support or prove medical necessity. I meet all applicable Medicare and State licensing requirements for the credential indicated below.

Signature *

Full Name *

Your signature

CMS Electronic Signature Certification: By checking this box, I certify that this typed signature constitutes my legal electronic signature. I authorize this signature to be used as my official signature for this Physician Certification Statement / Certificate of Medical Necessity form. I understand that this electronic signature has the same legal effect as a handwritten signature pursuant to 42 CFR § 424.36.

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Printed Name *

Credential *

Review & Submit

Important: 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.

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