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Forms & Documents – Case Managers


Advance Ambulance Physician’s Certification Statement (PCS)
Written authorization from a physician, physician’s assistant, nurse practitioner, clinical nurse specialist, discharge planner or registered nurse signifying that transport by ambulance is medically necessary and the patient’s condition at the time of transport meets medical necessity requirements. For an ongoing patient (multiple trips), the PCS must be signed by a physician.
Medicare Ambulance Guidelines for Medical Necessity
Medical necessity is established when the patient’s condition is such that the use of any other method of transportation would be hazardous to the patient’s health. This document outlines conditions to be met for medical necessity as well as provides a table reflecting different origination points and coverage.
Medicare Beneficiary Signature
Form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information.
Medicare Coverage of Ambulance Services Booklet
Booklet from Department of Health and Human Services that explains Medicare’s coverage of ambulance transportation, paying for ambulance services, Medicare Rights & Protections and definitions.
Advanced Beneficiary Notice (ABN)
According to Mayo Clinic, an ABN is a written notice from Medicare given to you before receiving certain items or services, notifying you:
•    Medicare may deny payment for that specific procedure or treatment.
•    You will be personally responsible for full payment if Medicare denies payment.
An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. It also offers you the right to appeal Medicare’s decision.
Medicare and You – 2017
Extensive official U.S. government Medicare handbook (152 pages) explaining all aspects of Medicare, enrollment, its coverages, patient rights and fraud protection, long-term care, obtaining more information and definitions.


Medicaid Ambulance and Medicar Coverage Guidelines
Document provides guidelines for ambulance and medicar coverages by Medicaid including prior approvals, approval procedures and a table reflecting different origination points and coverage.

 Non-Emergency Transportation Prior Approval Program (NETSPAP)

Certification of Transportation Services (CTS) – entry ready
Form must be completed and signed by a doctor or licensed professional for transport to non-emergency medical appointments upon request by First Transit.
Netspap Single Trip Form
Form must be completed by a facility for a single non-emergency trip.
Netspap Standing Prior Approval Form
Form must be completed by facility for prior authorization of non-emergency transportation (ongoing).
First Transit Trip Request Instruction in English
Document provides detailed trip request instructions from First Transit.
First Transit Trip Request Instruction in Spanish
Document provides detailed trip request instructions from First Transit.
Psychiatric Services Treatment Plan Form – for CAP/GAP Providers
 – entry ready
Form developed for non-emergency transportation that must be signed by the referring and direct service provider.
Psychiatric Services Treatment Plan Form – for Provider Type 36 Community Mental Health Services
 – entry ready
Form must be completed, dated and signed by the LPHA designated for the participant needing  non-emergency transportation services.
Medical Certification for Non-Emergency Ambulance (MCA)
– entry ready
Form required by law when an Illinois Medicaid participant is discharged from a hospital and is transported via ambulance. A patient’s condition must meet criteria for medical necessity in order to be transported via ambulance and the treating provider must certify that such criteria are met.

Other Helpful Forms and Documents

Illinois RN Continuing Education FAQs (Illinois Department of Financial and Professional Regulation)
Document covering Frequently Asked Questions for RN Continuing Education by the Illinois Department of Financial and Professional Regulation.
Privacy Practices Notice
Advance Ambulance’s notice describes how medical information about you may be used and disclosed and how you can get access to this information.


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