INSTRUCTIONS: Please submit this form and give a copy to the transportation provider. Do not submit an MCA Form for Hospital to Hospital transfers by ambulance for higher level of care as they do not require prior approval from First Transit.

IMPORTANT: A patient is only eligible for ambulance transportation if, at the time of discharge, he or she is unable to travel safely in a personal vehicle, taxi, or wheelchair van. Ambulance transport requests that are the patient's preference, or because assistance is needed at the discharging hospital or at home (to navigate stairs and/or to assist or lift the patient), and/or because another provider with the appropriate level or service is not immediately available do not meet the criteria and will not be eligible for reimbursement. Transportation must be to the nearest available appropriate provider.

PLEASE DO NOT LEAVE ANY FIELDS BLANK AS FIRST TRANSIT CANNOT PROCESS INCOMPLETE FORMS.

Patient Information

Only MCA forms that have the Recipient ID can be processed. If Medicaid is pending, please complete this form and give a copy to the transportation provider but do not submit it to First Transit.

Trip Information

The time format must be military 'HH:MM' format.

Pickup

Destination

Transport

Reason why patient needs ambulance transport (Complete A and B)

A. Choose one or more criteria boxes

The patient has a diagnosed or suspected communicable disease or hazardous material exposure and must be isolated from the public, or has a medical condition and must be protected from public exposure.

The patient requires the administration of supplemental oxygen by a third party assistant/attendant, or that the patient requires the regulation or adjustment of oxygen prior to and during transport, and is expected to require the treatment after transport.

The patient requires advanced continuous airway management by means of an artificial airway through tracheal intubation (nasotracheal tube, orotracheal tube, or tracheostomy tube) prior to and during transport, and is expected to require the treatment after transport.

The patient requires suctioning to maintain their airway, or that the patient requires assisted ventilation and/or apnoea monitoring, prior to and during transport, and is expected to require the treatment after transport.

The patient requires the administration of ongoing intravenous fluids prior to and during transport and is expected to require treatment after transport.

The patient requires administration of chemical restrain during transport, or is under the influence of a previously-administered chemical restraint prior to transport, and that the chemical restraint is for the explicit purpose of reducing the patient's functional capacity. The medication shall be ordered and documented in the medical record.

The patient requires physical restraints that are required prior to transport and which are maintained for the duration of the transport.

The patient requires one-on-one supervision due to a condition that places the patient and/or others at risk of harm or elopement for the duration of the transport.

The patient requires cardiac and/or respiratory monitoring, or hemodynamic monitoring, prior to, during and after transport.

The patient requires specialized handling for the purpose of positioning during transport.

The patient requires clinical observation from one environment with 24-hour clinical observation or treatment provided by certified or licensed nursing personnel to another environment with 24-hour clinical observation or treatment provided by certified or licensed nursing personnel. This criterion is not satisfied based solely on the type of hospital or other facility from which th patient is being transferred from or to.

B. Based on the criteria selected in Section A, detail the specific procedures, conditions, diagnosis, monitoring, medications, special handling, etc. that are required prior to, during and expected to continue after transport.

List the patient's medical diagnosis that supports criteria at time of discharge.

Certification and Attestation

You must select either A, B or C *

Option Explanation

A - The patient meets the HFS criteria for non-emergency ambulance transportation.

B - I have conferred with the physician or other authorized providers as set forth below, whose determination is that the patient meets the HFS criteria for non-emergency ambulance service.

C - The patient does not meet the HFS criteria for non-emergency ambulance transportation. I have provided my justification for ordering non-emergency ambulance transportation. This form does not constitute approval if this option is selected

Certification: I certify that the information in this document supplied for the patient criteria certification constitutes true, accurate and complete information and is supported in the medical record of the patient. I understand that the information I am supplying for the patient criteria will be utilized to determine approval of services resulting in payment of state and federal funds. I understand that falsifying entries, concealment of material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law, which can result in fines, civil monetary penalties or imprisonment, in addition to recoupment of funds paid and administrative sanctions authorized by law.