Forms
Below are several forms that may be helpful. Upon completing any form below, please submit it to Halifax EMS by one of the options below.
220 Ben Burton Circle, Suite A
Bogart, Ga 30622-6851
admin@halifaxems.com
Fax
706-243-4760
PCS Form for Halifax EMS.pdfPhysician Certification Statement (PCS)
This form needs to be completed for all non-emergency transports for that transport to be billable to insurance.
*Emergency transports do not require this form.
Medical Records Release - To Patient.pdfAuthorization 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.
Halifax EMS Hardship Policy 2024.pdfFinancial 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 and Physical : Assessment (H&P) for Halifax EMS.PDFHistory & 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.