Forms

Physician Certification Statement (PCS)

• This form needs to be completed for all non-emergency transports for that transport to be billable to insurance.

*Emergency transports to an Emergency Department do not require this form.

*In most cases, facilities listed as a 'clinic' or a 'physician office' are not covered by insurance. Please dial our office line with any questions at 770-545-7222.

Authorization for Release of Medical Records

• This form must be completed by the patient, patient's Power of Attorney, or a legal guardian of the patient. A fee may be associated with retrieving, printing, and/or mailing patient records.

Financial Hardship Policy

• This policy is made in accordance with the Federal Register by the Department of Health and Human Services (HHS). This policy's rates are updated yearly to reflect the most up-to-date information from HHS. Please reach out to us with any questions.

History & Physical (H&P)

• This form is to be completed by a healthcare provider when repetitive transport is needed for a patient (i.e. dialysis, wound care, chemo, radiation). This information is used to obtain a Prior Authorization with the patients insurance company.

• An updated H&P is usually required every 3 months by insurance.