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Non-Emergency Coding Clinic Claim Documents
© Copyright 2016-2017, PWW Media, Inc. All Rights Reserved. All Use Subject to Attendee License Agreement.
2016-2017 Program Materials
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License and Limitations of Use
Copyright Statement
Disclaimer
Entire Agreement
Background Information
The transport examples in the coding clinics were performed by “Mickey Mouse Ambulance,” a fictional, private, non-profit ambulance service serving the fictional “Magic Kingdom.” Mickey Mouse Ambulance has 6 vehicles, with six crew teams, as identified below. Within the Magic Kingdom are the fictional cities of Atlantica, Radiator Springs, Frontierland, Tomorrowland, Neverland, Fantasyland, Monstropolous, and Zootopia, as outlined on the attached map. The facilities and locations (other than private residences) where trips originate or end are listed below, and also appear on the map. In this Coding Clinic, we are deciding how to code these transports and to which payer the transports should be billed. In cases where the transport is not billable to Medicare (based on the information available for review) we must decide what steps to take.
Ambulance Crew Member Signature Log
Unit # Crew Member Name
Signature Specimen Certification Level
Certification Number
1
Peter Pan Peter Pan EMT-Paramedic P-00755
Tinker Bell Tinker Bell EMT-Paramedic P-00377
2
Donald Duck Donald Duck EMT-Paramedic P-00031*
Daisy Duck Daisy Duck EMT-Basic B-00014
3
Sebastian Mon Sebastian Mon EMT-Paramedic P-00823*
Flounder Ing Flounder Ing EMT-Basic B-00046
4
Hans Southern Hans Southern EMT-Basic B-00369
Kristoff Anderson Kristoff Anderson EMT-Basic B-00123
5
Celia Weelia Celia Weelia EMT-Basic B-00598
James P. Sullivan Sully EMT-Basic B-00623
6
Dopey Dwarf Dopey Dwarf EMT- Basic B-00765
Happy Dwarf Happy Dwarf EMT-Paramedic P-00978
* Advanced paramedic scope of practice includes: arterial line monitoring, ventilator operations and the following medication administrations: blood and blood products, antibiotic infusions, and heparin.
Assisted Living Dialysis Center
Community Hospital
Zootopia 99918
Urgent Care Clinic
General Hospital
Neverland 99915
Holy Spirit Hospital & Select LTACH
Medical Center Apartment
Fantasyland 99916
Power Plant
Radiator Springs 99912
Frontierland 99913
Tomorrowland 99911
©2016, Page, Wolfberg & Wirth, LLC
Golden SNF
Outpatient Center/ Freestanding Clinic
Monstropolous 99917
County Jail
Hotel Magic SNF
Good Samaritan Hospital
MAP OF MAGIC KINGDOM
End of the Road SNF
List of Facilities and Locations
Medical Center Trauma Center and 1,000 Bed Hospital 1 Magic Kingdom Way, Fantasyland 99916 General Hospital 500 Bed Hospital w/ ER 10 Atlantica View Rd., Neverland 99915 Good Samaritan Hospital 200 Bed Hospital w/ ER 14 Randall Dr., Monstropolus 99917 Holy Spirit Hospital 150 bed hospital w/ separate specialty center 100 14th St. Radiator Springs, 99912 Community Hospital 25 Bed Hospital and ER 6467 Race St., Zootopia, 99918 Select LTACH 10 Bed SNF, 20 Bed Hospital inside Holy Spirit Hospital (4th Floor) 100 14th St. Frontierland, 99913 Golden SNF 75 Bed SNF, with Hospice Care 2319 Sock Dr., Monstropolous, 99917 End of the Road SNF 100 Bed SNF & Hospice Care 17 Main St. Fantasyland, 99916
Magic SNF 100 Bed SNF and Assisted Living Facility 1501 Oswald St., Fantasyland, 99916 Assisted Living Personal Care Home, no skilled services offered 42 Wallaby Way, Atlantica, 99914 Dialysis Center Dialysis Center (not hospital based) 7878 Creek Run Road Frontierland 99913 Outpatient Center/Freestanding Clinic Ambulatory surgery, diagnostic services, Freestanding ED services Highway 15 North, Frontierland 99913 Apartment Complex 150 Units 500 Dwarf Street, Fantasyland 99916 Power Plant 2320 Atlantica View Rd., Neverland 99915 Hotel 99 Olaf St., Zootopia, 99918 Urgent Care Clinic 2004 Incredible Dr., Tomorrowland, 99911 County Jail 1001 Acorn Way, Monstropolous, 99917
Magic Kingdom - Response Determinants and Dispatch Codes Response/Transport Priority Alpha – BLS Cold (Non-emergency) Bravo – BLS Hot Charlie – ALS Cold (Non-emergency) Delta – ALS Hot Echo – ALS Hot Dispatch Codes 001 – Cardiac/ Heart Problems (ALS) 002 – Respiratory/Breathing Problems (ALS) 003 – Fall – greater than 10 feet (ALS) 004 – Fall – less than 10 feet (BLS) 005 – Animal Bite – with other symptoms (ALS) 005 – Animal Bite – no other symptoms (BLS) 006 – Fracture – with other symptoms (ALS) 007 – Fracture – without other symptoms (BLS) 008 – Gunshot/Stab Wound – dangerous body part/bleeding not under control (ALS) 009 – Gunshot/stab wound – not dangerous body part/bleeding under control (BLS) 010 – Hemorrhage/Bleeding – dangerous body area or 2° symptoms (e.g. vomiting/pain) (ALS) 011 – Hemorrhage/bleeding – not dangerous body area or minor bleeding (BLS) 012 – Seizure Activity (ALS) 013 – Altered Mental State – other symptoms (ALS) 014 – Altered Mental State – no other symptoms (BLS) 015 – Sick Person, Man Down, unknown status (ALS) 016 – Sick Person, known status, minor condition (BLS) 017 – CVA/Stroke (ALS) 018 – Mass/Multiple Trauma (ALS) 019 – Fever – no other symptoms (BLS) 020 – Pain – no other symptoms < 4/10 on pain scale (BLS) 021 – Pain – other symptoms, >4/10 on pain scale (ALS) 022 – Choking – alert, awake, no other symptoms (BLS) 023 – Diabetic Problems (BLS) 024 – Eye Problem (BLS) 025 – Headache (BLS) 026 – Syncope/Vertigo (BLS) 027 – Pregnancy/Childbirth (BLS) 028 – Overdose (ALS) 029 – Psychiatric/Suicidal (BLS) 030 – Heat/Cold Exposure (BLS) 031 – Burns 1st degree or less than 10% of body (BLS) 032 – Burns 2nd or 3rd degree or greater than 10% of body (ALS) 033 – Non-emergency Interfacility Transfer / Palliative Care / Discharge 034 – Welfare Check (BLS) Approved: Mickey Mouse, MD, CEO Date: 7/1/2015
Magic Kingdom Department of Health - Approved ALS Drugs
1. Activated Charcoal 2. Adenosine 3. Albuterol 4. Amiodarone 5. Aspirin 6. Atropine 7. Calcium Chloride 8. Diazepam 9. Dilaudid 10. Diltiazem 11. Diphenhydramine HCL 12. Epinephrine 13. Fentanyl 14. Furosemide 15. Glucagon 16. Intravenous solutions (Dextrose, NaCl, Lactated Ringer’s) 17. Lidocaine 18. Lorazepam 19. Magnesium Sulfate 20. Midazolam 21. Morphine 22. Naloxone HCL (Narcan) IV 23. Nitroglycerin 24. Ondansetron 25. Sodium bicarbonate
+ EMT-B scope of practice includes transport of a patient with an existing IV lock, O2 administration, BGL check, and Narcan administration IM.
Signed:
Walt Disney, MD Medical Director, Magic Kingdom Department of Health
Effective Date: 7/1/2015
abc360 Coding Clinic – Checklist – Non-Emergency
Run # Med
ical
Nec
essit
y Do
cum
ente
d? (Y
/N)
Reas
onab
lene
ss M
et?
(Y
/N)
Tran
spor
t to
Cove
red
Dest
inat
ion?
(Y
/N)
Mile
age
Reco
rded
? (Y
/N)
PCS
Crite
ria M
et?
(Y/N
)
Sign
atur
e Va
lid fo
r Cla
im
Subm
issio
n? (Y
/N)
Coding Comments
201 NE
202 NE
203 NE
204 NE
205 NE
206 NE
207 NE
Run 201-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 201 NE PATIENT NAME: Charlotte La Boeff DATE OF SERVICE: 8/14/16
Times Response Information Mileage
CALL RECV’D 11:00:02
DISPATCH CODE 004- Fall BLS
TO SCENE 0.0
DISPATCH 11:35:14
RESPONSE PRIORITY Alpha
ON SCENE 0.0
ENROUTE 11:35:56
LOCATION
Magic SNF, 1501 Oswald St., Fantasyland, 99916
ENROUTE TO DEST. 0.0
ON SCENE 11:46:15
TRANSPORTED TO
Medical Center, 1 Magic Kingdom Way, Fantasyland, 99916
AT DEST. 7.0
DEPART SCENE 12:10:34
TRANSPORT PRIORITY Alpha
TOTAL LOADED
MILEAGE 7.0
ARRIVE DEST. 12:25:18 DISPATCH COMMENTS: Multiple ground level falls today Demographic
NAME Charlotte La Boeff
DOB 12/08/1943
AGE 72
WEIGHT 125 lbs
ADDRESS 1307 Hunt St. Fantasyland, 99916
SEX F
Initial Information CHIEF
COMPLAINT Pain, weakness all over body PT FOUND Lying on couch
MEDICAL HX Falls, cancer
MEDICATIONS Multiple
ALLERGIES NKDA
IMPRESSION Weakness
Narrative
Initial BLS Assessment: GCS: 15 (4/5/6); Skin: Warm, Normal; Eyes: PEARL; General Exam Finding: Weakness Unit 5 responded to call for fall. Arrived on scene at above location to find 72 YOF lying on a couch in the resident rec room at the facility, with facility staff reporting that pt. fell multiple times today. Pt. is in the assisted living wing of the facility, not receiving skilled care. No obvious injuries noted – pt. denies pain to lower extremities. Pt. denies LOC, or head/neck injury. Full head to toe assessment reveals no head/neck/spine injuries. Pt. reports feeling weak for previous two days and when she tries to walk, “my legs just give out.” Nursing staff from facility recommended pt. be transported to hospital for evaluation. Pt. reports that SNF facility is cold and she has trouble sleeping at night such that she is weak and tired during the day. Pt. found to have low SpO2 level (80%), so O2 administered at 4 LPM. After several minutes, SpO2 increased to 100%. Pt. denies prior history of respiratory problems. Pt. denies SOB, chest pain, or other symptoms.
Treatment Log
TIME
B/P
HR RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
11:50:15 80% BLS Assessment O2 4-LPM (NC) - hypoxia
12:14:35 125/78 102 20 90%
Crew Information
Lead Celia Weelia CERT# B-00598
LEVEL B
SIGNATURE
Celia Weelia
Driver James P. Sullivan CERT# B-00623
LEVEL B
SIGNATURE Sully
Mickey Mouse Ambulance Signature/Claim Submission Authorization Form
Patient Name: Charlotte La Boeff Transport Date: 8/14/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Describe the circumstances that make it impractical for the patient to sign: ALOC
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient
X Eli La Boeff 8/14/16 Eli La Boeff, spouse
Representative Signature Date Printed Name of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X Patient Signature or Mark Date Witness Signature Date
Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time: A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport) My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the
authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
X Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
X_____________________________________ ____________ ____________________________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
Physician Certification Statement for Non-Emergency Ambulance Services
Section 2 - Medicare Definition of “Medical Necessity” for Ambulance Transportation:
Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.
The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.
Nonemergency transportation by ambulance is appropriate if either:
o The beneficiary is bed-confined, and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or,
o If his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.
Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations.
For a beneficiary to be considered bed-confined, the following criteria must be met:
o The beneficiary is unable to get up from bed without assistance. o The beneficiary is unable to ambulate. o The beneficiary is unable to sit in a chair or wheelchair.
The medical necessity definition above appears exactly as it is contained in 42 C.F.R. § 410.40.
Section 3 - Certification
I certify that the medical necessity requirements set forth above for ambulance services are met.
8/15/16
Signature Date
____________Jacques Facilier_, MD_____________________________________ Printed Name and Credentials of Physician* or Healthcare Professional (REQUIRED)
*For scheduled, repetitive transports, this form must be signed by the patient’s attending physician. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.
For non-repetitive or unscheduled transports, this form may be signed by one of the following if the signature of the attending physician cannot be obtained:
● Registered Nurse ● Discharge Planner ● Nurse Practitioner ● Physician Assistant ● Clinical Nurse Specialist
Section 1 – Patient Information
Patient Name: Charlotte La Boeff Date of Birth: 12/08/1943 Transport Date: 8/14/16
Run 202-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 202 NE PATIENT NAME: Rudy Oldgye DATE OF SERVICE: 8/1/2016
Times Response Information Mileage
CALL RECV’D
19:59:12 (7/31/2016)
DISPATCH CODE 033 - Interfacility
TO SCENE
DISPATCH
05:46:16 (8/1/2016)
RESPONSE PRIORITY Charlie
ON SCENE
ENROUTE 05:46:12
LOCATION
Good Samaritan Hospital, 14 Randall Dr. Monstropolous, 99917
ENROUTE TO DEST. 0.0
ON SCENE 06:03:56
TRANSPORTED TO
Medical Center, 1 Magic Kingdom Way, Fantasyland 99916
AT DEST. 4.0
DEPART SCENE 06:20:00
TRANSPORT PRIORITY Charlie
TOTAL LOADED
MILEAGE 4.0
ARRIVE DEST. 06:32:17 DISPATCH COMMENTS: Cardiac patient – requires cath lab services Demographic
NAME Rudy Oldgye
DOB 03/05/1939
AGE 77
WEIGHT 196 lbs
ADDRESS 200 Lakefront Ave., Frontierland, 99913
SEX M
Initial Information CHIEF
COMPLAINT Cardiac Catheterization PT FOUND Ambulating in room
MEDICAL HX
Arthritis, HTN, Cardiac stent, MI, CAD, Hyperlipidemia, DM- II
MEDICATIONS Not listed
ALLERGIES Sulfa
IMPRESSION Cardiac monitoring required
Narrative
Unit 6 responded to request for NE transfer for cath lab services not available at origin. Patient had recent catheterization, but some of the occluded vessels were unable to be opened. Initial plan was to treat medically, and an additional catheterization would later be attempted. Pt. continued to experience symptoms and was admitted with negative enzymes so the plan is to take him to the cath lab for second attempt to reestablish flow. Pt. denies any distress, and has stable vitals, O2 saturation at 99%. Pt. transferred self to stretcher without assistance. EKG shows Sinus Rhythm with 1st degree block and occasional PVCs. Heart Sounds = S1, S2, without murmurs or gallops noticed. GCS=15, patient remains free of distress during transport. IV remains intact without edema or leaking. Upon arrival at destination facility, pt. unloaded from ambulance and transported to cath lab, where pt. self- transferred to bed without assistance. Bedside report given to RN. Assessment: Airway: Patent; Breath Sounds: Clear, Equal; LOC: A&Ox4; Circulation: Cap refill less than 2 seconds; CNS: Neuro intact; Head: Assessed with no abnormalities; Upper extremities: Assessed with no abnormalities; Lower extremities: Assessed with no abnormalities; Skin: Normal, elastic, moist, smooth
Treatment Log
TIME
B/P
HR RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
PTA IV – other healthcare professional 20 G
06:07 150/90 76 18 99% LS = clear, equal, bilateral EKG – 1st Degree AV Block
Crew Information
Lead Happy Dwarf CERT# P-00978
LEVEL P
SIGNATURE
Happy Dwarf
Driver Dopey Dwarf CERT# B-00765
LEVEL B
SIGNATURE Dopey Dwarf
Mickey Mouse Ambulance Signature/Claim Submission Authorization Form
Patient Name: Rudy Oldgye Transport Date: 8/1/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample o
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Describe the circumstances that make it impractical for the patient to sign:
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient
X Representative Signature Date Printed Name of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X Rudy Oldgye 8/1/16 Patient Signature or Mark Date Witness Signature Date
Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time: A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport) My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
X Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
X_____________________________________ ____________ ____________________________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
Good Samaritan Hospital
Electronic Ambulance Certification Form Patient Name (Last) Oldgye (First) Rudy Transport Date: 8/1/16 Patient DOB: 03/05/1939 Transport To: Medical Center, 1 Magic Kingdom Way, Fantasyland 99916 Patient requires cardiac catheterization services not available at origin hospital. Patient is being transferred to nearest appropriate facility with these services. Is the Patient Bed confined by Medicare (CMS) regulations? Yes No If yes, state condition or diagnosis for bed confinement: If no, can the patient be transported by wheelchair van? Yes No If no, list appropriate medical conditions which necessitate transport by ambulance and make all other means of transport contraindicated based on patient’s safety and health. (Supporting documentation for any conditions listed must be maintained in the patient’s health record). Patient requires constant cardiac monitoring due to partial blocked cardiac artery and need for catheterization services. Pt. is unstable, and could suffer an acute cardiac event at any time. I certify that the above information is true and correct based on my evaluation of this patient, to the best of my knowledge and professional training. I understand that this information will be used by the ambulance service transporting this patient to satisfy CMS requirements, for purposes of determining medical necessity for ambulance services. Electronically signed by: Date/Time: Emperor Kuzco, PAC 8/1/16 / 05:30
Patient Demographic Information
Reason for Transfer (Explain)
Medical Necessity for Ambulance
Certification
Run 203-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 203 NE PATIENT NAME: Percival McLeach DATE OF SERVICE: 7/31/16
Times Response Information Mileage
CALL RECV’D 17:30:22
DISPATCH CODE 033 Interfacility
TO SCENE 0.0
DISPATCH 17:55:58
RESPONSE PRIORITY Alpha
ON SCENE 4.3
ENROUTE 17:58:09
LOCATION
General Hospital, 10 Atlantica View Rd., Neverland 99915
ENROUTE TO DEST. 4.3
ON SCENE 18:15:45
TRANSPORTED TO
Holy Spirit Hospital, 100 14th St. Radiator Springs, 99912
AT DEST. 9.9
DEPART SCENE 19:29:32
TRANSPORT PRIORITY Charlie
TOTAL LOADED
MILEAGE 5.6
ARRIVE DEST. 20:08:13 DISPATCH COMMENTS: Interfacility transfer – liver transplant Demographic
NAME Percival McLeach
DOB 04/13/1951
AGE 65
WEIGHT 187 lbs
ADDRESS 200 Magic Drive, Neverland, 99915
SEX M
Initial Information CHIEF
COMPLAINT Liver transplant PT FOUND In hospital bed
MEDICAL HX
Diabetes, hypertension, Hepatic- liver failure, Gastric reflux
MEDICATIONS Attached
ALLERGIES NKDA
IMPRESSION Hemodynamic monitoring required
Narrative
Unit 5 was initially dispatched for routine BLS non-emergency transfer for higher level of care for liver transplant. Upon arrival, crew met with RN for a report, who noted the patient has an indwelling arterial line. The BLS crew advised RN they were not able to transport patient without higher trained Paramedic, and contacted dispatch and try to locate higher trained personnel. I was then dispatched to assist, and I arrived on scene approximately 30 minutes later. Upon my arrival, I received a complete summary of the patient, including a past complaint of shortness of breath, with led to a diagnosis of hydrothorax. Pt. had pleural chest tube placed, and 4 liters of fluid was withdrawn about 1 week ago. The pt. became acutely hypotensive, and was admitted to ICU, and acute liver disease was diagnosed. Pt. also reported a recent (unintended) 50 lb. weight loss in past 6 months. Assessment revealed: Chest: Lungs CTA bilaterally, no wheeze, rales, or rhonchi; RR: 20-24, with no cough, with pleural chest tube located on right side, clamped by RN for transport. Tube was set to gravity drain via Pleuravac system. No fluid is noticed in the tube, but old, dark blood was observed in the Pleuravac. Cardiac: EKG reveals sinus tachycardia without ectopy. Abdomen: Significant distension of the abdomen noticed, and pt. denies discomfort; Skin: Warm, dry; Extremities: Thin, weak. Pt. is unable to stand or ambulate on his own since this admission into ICU (per nurse) but previously was active (per pt.). Left brachial artery line is patent – draws and flushes easily. Dressing is clean, clear, and intact. Left femoral triple lumen PICC line is currently capped. Treatments while enroute: Continuous monitoring of cardiac rhythm, BP, SpO2, arterial line, and chest tube. Upon arrival at destination, report given to receiving RN. Unit 5 crewmembers accompanied patient in transport, with Celia Weelia driving, and James P. Sullivan accompanying me in the patient compartment. End of narrative: Sebastian Mon, EMT-P.
Treatment Log
TIME
B/P
HR
RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
18:45 93/60 102 20 96% GCS=15 (4/5/6) EKG: ST
19:22 89/62 100 24 94%
Crew Information
Lead Sebastian Mon CERT# P-00823
LEVEL P
SIGNATURE
Sebastian Mon
Driver Celia Weelia CERT# B-00598
LEVEL B
SIGNATURE Celia Weelia
Additional James P. Sullivan CERT# B-00623 LEVEL B SIGNATURE Sully
Physician Certification Statement for Non-Emergency Ambulance Services
SECTION I – GENERAL INFORMATION
Patient’s Name: Percival McLeach Date of Birth: 4/13/51
Transport Date: (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)
Origin: General Hosptial Destination: Holy Spirit Hospital
Is the pt’s stay covered under Medicare Part A (PPS/DRG?) YES NO
Closest appropriate facility? YES NO If no, why is transport to more distant facility required?
If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility: liver transplant
If hospice pt, is this transport related to pt’s terminal illness? YES NO Describe:______________________________________________
SECTION II – MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition:
Cardiac monitoring, arterial central line in place, liver transport required with hemodynamic monitoring required enroute
2) Is this patient “bed confined” as defined below? Yes No To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair
3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:
*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records
Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement
Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints
DVT requires elevation of a lower extremity Medical attendant required Requires oxygen – unable to self administer
Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport
Hemodynamic monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds
Cardiac monitoring required enroute Morbid obesity requires additional personnel/equipment to safely handle patient
Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport
Other (specify) Pleuravac, chest tube, arterial line – higher level care required during transport
SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows:
7/31/16 Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for
transports performed more than 60 days after this date). Clara Belle Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.)
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Mickey Mouse Ambulance Signature/Claim Submission Authorization Form
Patient Name: Percival McLeach Transport Date: 7/31/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample o
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Describe the circumstances that make it impractical for the patient to sign:
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but
furnished other care, services, or assistance to the patient X Representative Signature Date Printed Name of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X Percival McLeach 7/31/16 Patient Signature or Mark Date Witness Signature Date
Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time:
A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)
My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
X Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
X_____________________________________ ____________ ____________________________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
Run 204-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 204 NE PATIENT NAME: Arlo Apatosaurus DATE OF SERVICE: 10/3/16
Times Response Information Mileage
CALL RECV’D
DISPATCH CODE 033 – BLS Transfer
TO SCENE 283410.5
DISPATCH 09:34:15
RESPONSE PRIORITY Alpha
ON SCENE 283415.6
ENROUTE 09:35:47
LOCATION
Dialysis Center, 7878 Creek Run Road Frontierland 99913
ENROUTE TO DEST. 283415.6
ON SCENE 09:45:57
TRANSPORTED TO
915 Oak St., Tomorrowland, 99911
AT DEST. 283430.3
DEPART SCENE 09:49:14
TRANSPORT PRIORITY Alpha
TOTAL LOADED
MILEAGE 14.7
ARRIVE DEST. 10:12:56 DISPATCH COMMENTS: Dialysis patient (T/TH/SA); PCS on FIle Demographic
NAME Arlo Apatosaurus
DOB 12/03/1950
AGE 65
WEIGHT 275 lbs
ADDRESS 915 Oak St., Tomorrowland, 99911
SEX M
Initial Information CHIEF
COMPLAINT Dialysis PT FOUND In bed
MEDICAL HX HTN, diabetes, ESRD
MEDICATIONS Unknown
ALLERGIES None
IMPRESSION Post-dialysis transfer
Narrative
Unit 4 was dispatched to above location for transport of 65 yom to private residence post dialysis treatment. Pt. presented in supine position in reclined dialysis chair, awaiting our arrival. Pt. was A&O x4, receiving oxygen. Pt. was secured to the stretcher with rails up and straps applied because of general weakness and fall risk. Patient has a medical history that includes hypertension, ESRD, diabetes. Pt. vitals were noted below. Pt. was transported without incident to private residence where he was left to the care of himself. Pt. was left in hospital style bed in the living room on the first floor.
Treatment Log
TIME
B/P
HR RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
09:48 128/68 72 16 97% GCS=15 (4/5/6)
Crew Information
Lead Hans Southern CERT# B-00369
LEVEL B
SIGNATURE
Hans Southern
Driver Kristoff Anderson CERT# B-00123
LEVEL B
SIGNATURE Kristoff Anderson
Physician Certification Statement for Non-Emergency Ambulance Services
SECTION I – GENERAL INFORMATION
Patient’s Name: Arlo Apatosaurus Date of Birth: __12/3/1950_________
Transport Date(s):8/3/16 – 10/3/16 (PCS is valid for round trips on this date and for all repetitive trips)
Origin: Residence Destination: Dialysis Center
Is the pt’s stay covered under Medicare Part A (PPS/DRG?) YES NO
Closest appropriate facility? YES NO If no, why is transport to more distant facility required?
If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:
If hospice pt, is this transport related to pt’s terminal illness? YES NO Describe:______________________________________________
SECTION II – MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition:
Pt. is bed bound
2) Is this patient “bed confined” as defined below? Yes No
To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair
3) Can this patient safely be transported by car or wheelchair van (i.e., seated without monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:
*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records
Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement
Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints
DVT requires elevation of a lower extremity Medical attendant required Requires oxygen – unable to self administer
Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport
Hemodynamic monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds
Cardiac monitoring required enroute Morbid obesity requires additional personnel/equipment to safely handle patient
Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport
Other (specify)
SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL
I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: Ralph C. Reilly, MD 8/1/2016 Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for
transports performed more than 60 days after this date). Ralph C. Reilly, MD Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner
Run 205-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 205 NE PATIENT NAME: Bing Bong DATE OF SERVICE: 7/22/16
Times Response Information Mileage
CALL RECV’D 10:55:36
DISPATCH CODE 033 – Interacility Transfer
TO SCENE
DISPATCH 13:27:28
RESPONSE PRIORITY Charlie
ON SCENE
ENROUTE 13:31:59
LOCATION
Magic SNF, 1501 Oswald St., Fantasyland, 99916
ENROUTE TO DEST. 236967.0
ON SCENE 14:05:00
TRANSPORTED TO
End of the Road SNF, 17 Main St. Fantasyland, 99916
AT DEST. 236868.0
DEPART SCENE 14:32:49
TRANSPORT PRIORITY Charlie
TOTAL LOADED
MILEAGE 1.0
ARRIVE DEST. 14:37:03 DISPATCH COMMENTS: Pt. on low dose morphine drip Demographic
NAME Bing Bong
DOB 08/09/1947
AGE 68
WEIGHT 215 lbs
ADDRESS 18 Wagon Way, Fantasyland 99916
SEX M
Initial Information CHIEF
COMPLAINT Transfer for end of life care PT FOUND Lying in bed
MEDICAL HX HTN, Renal Failure, Dementia, Lung Cancer
MEDICATIONS No current medications recorded
ALLERGIES NKDA
IMPRESSION Transfer for hospice care
Narrative
Unit 2 responded to above location for interfacility transport of patient requiring IV morphine administration and monitoring. Pt. found lying supine in bed, A&Ox2. Pt. was diagnosed with end-stage cancer and has elected hospice benefits. Patient has been at origin SNF for 2 years, and is no longer in a Part A stay. Origin SNF does not provide hospice services, and is being transferred for end of life care. Pt. was moved to stretcher via draw sheet method and secured with 2 straps. Pt. denies SOB, dizziness. Pt. is transported with O2 at 15 lpm via NRB. Assessment: HEENT, PEARL, no JVD, no tracheal deviation, equal chest rise/fall, L/S clear, equal, ABD is soft/non-tender in all 4 quadrants, pelvis is stable and intact. Upper and lower extremities have PMS, but contractures and weakness. Pt. is unable to tolerate sitting position, and is unable to ambulate, or get up from bed. Pt. meets the Medicare bed confined requirement. Pt. was transported in a position of comfort to End of the Road SNF, and remained stable during transport. No additional Morphine was required, due to short distance transport. Upon arrival, pt. was transferred to Bed 501 by draw sheet method and transfer of care given to LPN for further care. Signature obtained from Minnie Mouse, as representative of sending facility, due to patient’s inability to sign.
Treatment Log
TIME
B/P
HR RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
PTA Morphine drip
14:09 140/75 80 12 100% GCS = 14 (6/4/4) O2 15 LPM (NRB)
14:35 Monitor morphine drip
Crew Information
Lead Donald Duck CERT# P-00031
LEVEL P
SIGNATURE
Driver Daisy Duck CERT# B-00014
LEVEL B
SIGNATURE Daisy Duck
Physician Certification Statement for Non-Emergency Ambulance Services
Section 2 - Medicare Definition of “Medical Necessity” for Ambulance Transportation:
Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.
The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.
Nonemergency transportation by ambulance is appropriate if either:
o The beneficiary is bed-confined, and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or,
o If his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.
Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations.
For a beneficiary to be considered bed-confined, the following criteria must be met:
o The beneficiary is unable to get up from bed without assistance. o The beneficiary is unable to ambulate. o The beneficiary is unable to sit in a chair or wheelchair.
The medical necessity definition above appears exactly as it is contained in 42 C.F.R. § 410.40.
Section 3 - Certification
I certify that the medical necessity requirements set forth above for ambulance services are met.
Minnie Mouse 7/22/16
Signature of Physician* or Healthcare Professional Date Signed
Minnie Mouse, RN Printed Name and Credentials of Physician* or Healthcare Professional (REQUIRED)
*For scheduled, repetitive transports, this form must be signed by the patient’s attending physician. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.
For non-repetitive or unscheduled transports, this form may be signed by one of the following if the signature of the attending physician cannot be obtained:
● Registered Nurse ● Discharge Planner ● Nurse Practitioner ● Physician Assistant ● Clinical Nurse Specialist
Section 1 – Patient Information
Patient Name: Bing Bong Date of Birth: 08/09/1947 Transport Date: 7/22/16
Mickey Mouse Ambulance Signature/Claim Submission Authorization Form
Patient Name: Bing Bong Transport Date: 07/22/2016 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample o
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Describe the circumstances that make it impractical for the patient to sign: ALOC, dementia, confusion, A&Ox2
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance
services) but furnished other care, services, or assistance to the patient
X Minnie Mouse 7/22/16 Minnie Mouse, RN Representative Signature Date Printed Name of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X Patient Signature or Mark Date Witness Signature Date
Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time:
A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)
My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
X Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
X_____________________________________ ____________ ____________________________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
Attestation Statement - Ambulance Crew Members
Name of Patient: Bing Bong Run Number/DOS: 205 NE/ 7/22/16
“I, Donald Duck [print full name of the crewmember that signed the PCR], hereby attest that the PCR dated 7/22/16 [date of service] accurately reflects signatures/notations that I made in my capacity as the treating Paramedic [insert specific crewmember level of certification (EMT-B, EMT-I, Paramedic, etc.)] when I treated and/or transported the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
Donald Duck
Signed
Donald Duck, EMT-P
Printed Name
7/31/16
Date
Run 206-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 206 NE PATIENT NAME: Destiny Whale DATE OF SERVICE: 7/17/2016
Times Response Information Mileage
CALL RECV’D 18:13:47
DISPATCH CODE 033 - Discharge
TO SCENE 266186.0
DISPATCH 18:33:51
RESPONSE PRIORITY Charlie
ON SCENE
ENROUTE 18:35:35
LOCATION
Community Hospital, 6467 Race St., Zootopia, 99918
ENROUTE TO DEST. 266187.0
ON SCENE 18:43:35
TRANSPORTED TO
Apartment Complex, 500 Dwarf Street, Apt. 2C Fantasyland 99916
AT DEST. 266187.0
DEPART SCENE 19:38:46
TRANSPORT PRIORITY Alpha
TOTAL LOADED
MILEAGE 0.0
ARRIVE DEST. 19:56:33 DISPATCH COMMENTS: Demographic
NAME Destiny Whale
DOB 4/15/49
AGE 67
WEIGHT 210 lbs
ADDRESS 500 Dwarf Street, Apt. 2C Fantasyland 99916
SEX F
Initial Information CHIEF
COMPLAINT Status Post Chest Pain PT FOUND In bed
MEDICAL HX Diabetes
MEDICATIONS None recorded
ALLERGIES None
IMPRESSION Transfer
Narrative
Unit 1 dispatched for ALS non-emergency transport for 67 yof status post chest pain. Pt. was admitted 7/10/16, and is now being discharged due to being complaint/symptom free. Upon arrival at pt. room, pt. is found to be A&Ox3 GCS=15. Pt. was lying semi-fowlers in hospital bed, and was assisted off bed and onto stretcher and secured with straps and railings x2. Patient was safely loaded into ambulance and assessed. Vitals determined to be w/n/l for her, and rest of exam was unremarkable. Pt. had equal chest rise and fall and abdomen was soft and non-tender x4. Pt. had positive PMS to all 4 extremities, but with weakness in legs leaving her unable to safely walk on her own without assistance from personnel. Pt. was brought back to her residence at BLS level, because pt. had weakness to lower extremities leaving her unable to sit safely during transport or support herself. Pt. was assisted off stretcher at lobby of apartment complex. Pt. stated she wished to stay in lobby with her sister and neighbor, and did not want to be taken to her apartment at the moment. Pt. signed that she would be staying in her own care with her sister and neighbor.
Treatment Log
TIME
B/P
HR RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
19:19 116/64 68 18 ALS assessment – normal A&Ox4
19:35 112/62 66 16 GCS = 15 (6/5/4)
Crew Information
Lead Peter Pan CERT# P-00755
LEVEL P
SIGNATURE
Peter Pan
Driver Tinker Bell CERT# P-00377
LEVEL P
SIGNATURE Tinker Bell
Mickey Mouse Ambulance Signature/Claim Submission Authorization Form
Patient Name: Destiny Whale Transport Date: 7/10/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample o
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Describe the circumstances that make it impractical for the patient to sign: cardiac problem
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance
services) but furnished other care, services, or assistance to the patient
X Charity Whale 7/10/16 Charity Whale, sister
Representative Signature Date Printed Name of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X Patient Signature or Mark Date Witness Signature Date
Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time:
A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)
My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
X Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
X_____________________________________ ____________ ____________________________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
Physician Certification Statement for Non-Emergency Ambulance Services
SECTION I – GENERAL INFORMATION
Patient’s Name: Destiny Whale Date of Birth: ___4/15/49________
Transport Date: 7/17/2016 (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)
Origin: Community Hospital Destination: Residence 500 Dwarf Streetr, Apt. 2C
Is the pt’s stay covered under Medicare Part A (PPS/DRG?) YES NO
Closest appropriate facility? YES NO If no, why is transport to more distant facility required?
If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:
If hospice pt, is this transport related to pt’s terminal illness? YES NO Describe:______________________________________________
SECTION II – MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition:
Weakness, difficulty ambulating
2) Is this patient “bed confined” as defined below? Yes No
To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair
3) Can this patient safely be transported by car or wheelchair van (i.e., seated, withouy monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:
*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records
Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement
Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints
DVT requires elevation of a lower extremity Medical attendant required Requires oxygen – unable to self administer
Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport
Hemodynamic monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds
Cardiac monitoring required enroute Morbid obesity requires additional personnel/equipment to safely handle patient
Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport
Other (specify)
SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL
I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: Fergus King 7/17/2016
Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for
transports performed more than 60 days after this date). Fergus King, MD Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner
Client: Mickey Mouse Ambulance
Trip ID #: 206 NE
Patient: Destiny Whale
Date of Service: 7/17/16
From: Community Hospital, 6467 Race St., Zootopia, 99918
To: Apartment Complex, 500 Dwarf Street, Apt. 2C Fantasyland 99916
Loaded Miles: 13.5
Directions Plotted: 8/17/16 15:59
Source: Mileage calculated from Mapquest on Import
Instruction Distance Unit Depart 6467 Race St., towards Rte 30. 0.4 Miles Take entrance ramp to Rte 30 North 0.1 Miles Merge onto Route 83/322 8.7 Miles Follow signs for Rte/. 322 East 1.3 Miles Exit at Fantasyland Exit/ Middle Rd 2.4 Miles Follow Middle Rd. to Dwarf St. 0.1 Miles Turn left onto Dwarf Rd., destination is ½ mile on right 0.5 MIles
Run 207-NE
2016-2017 Program Materials
Mickey Mouse Ambulance
Patient Care Report
RUN NUMBER: 207 NE PATIENT NAME: Flash E. Pants DATE OF SERVICE: 7/1/2016
Times Response Information Mileage
CALL RECV’D 14:57:14
DISPATCH CODE 034 – Welfare Check (BLS)
TO SCENE 0.0
DISPATCH 14:58:01
RESPONSE PRIORITY Alpha
ON SCENE 1.0
ENROUTE 14:58:54
LOCATION
250 Ivy Lane, Zootopia, 99918
ENROUTE TO DEST. 1.0
ON SCENE 15:02:08
TRANSPORTED TO
Community Hospital, 6467 Race St., Zootopia, 99918
AT DEST. 6.3
DEPART SCENE 15:11:12
TRANSPORT PRIORITY Bravo
TOTAL LOADED
MILEAGE 5.3
ARRIVE DEST. 15:23:33 DISPATCH COMMENTS: Welfare check – patient possibly involved in MVA and fled Demographic
NAME Flash E. Pants
DOB 11/25/1939
AGE 76
WEIGHT 164 lbs
ADDRESS 250 Ivy Lane, Zootopia, 99918
SEX M
Initial Information CHIEF
COMPLAINT Knee pain PT FOUND On couch
MEDICAL HX Unknown
MEDICATIONS None reported
ALLERGIES NKDA
IMPRESSION
Narrative Unit 3 was advised by dispatch that Unit 1 was dispatched to the scene of a single vehicle MVA. Per dispatch, single occupant driver was reported to have been driven away from the scene by bystanders, and his SUV was found partially over the side of the roadway. Police and Unit 1 remained on scene, and Unit 3 was dispatched to perform a welfare check (along with PD) at driver’s home. Unit 3 arrived at patient’s home to find P.O. Judy Hopps already on scene. Pt. found conscious, in mild distress, sitting on a chair, watching t.v. Pt. recounted the events of the accident to Unit 3 personnel and P.O. Hopps. Pt. denied LOC, and initially refused care. Pt. agreed to be seen at ED for full evaluation, but chose POV for transport. P.O. Hopps offered to take pt. in her squad car. EMS provided assistance, while pt. tried to ambulate. When pt. was unable to navigate through the house and onto the porch, pt. agreed that ambulance transport would be preferred. Pt. stated he experienced significant pain (rated 7/10) while trying to make his way through the house. Pt. admitted to EMS that he was not wearing a seat-belt at the time of the crash, and the reason he fled was because he has an expired license and was scared he would be in trouble. Upon assessment, pt. presented with slight hypertension, with GCS =15, skin normal, warm, and dry. Head, neck and back were negative to pain on palpation, and pt. demonstrated full spinal ROM on request, without difficulty. Facial structures intact, with tenderness reported to left cheekbone. Clear lung sounds bilaterally to auscultation, with equal chest wall expansion. Pelvis intact to tilt and compression. Left hip rated 4/10 on pain scale, left knee rated 7/10. Minor 2 cm abrasion noted to shins bilaterally, and 3 cm abrasion noted to left thigh, and full thickness laceration to left middle finger. Minor pain reported to right wrist, and knuckle of right hand, with minor swelling and pain (rated 2/10). Pt. denies use of ASA or blood thinners. Pt. injuries determined to be conducive with description of the accident and MOI. Pt agreed to go to Community Hospital. Pt. moved to ambulance, moderate wounds dressed, and wrist splinted. P.O. Judy Hopps accompanied pt. to hospital to be able to continue to take information and statement from pt. regarding accident.
Treatment Log
TIME
B/P
HR
RR
SPO2 ETCO2
TEMP
EXAM (NEURO, RR, CV, ABD, SKIN)
TREATMENT (O2, MED, PIV, EXTRICATION)
15:05 155/78 68 16 100% ALS assessment (findings above)
15:10 GCS = 15 (6/5/4) Wound care bandaging, splinting
15:17 155/86 64 16 GCS=15 (6/5/4) enroute
15:27 155/76 65 16 100% At destination
Crew Information
Lead Sebastian Mon CERT# P-00823
LEVEL P
SIGNATURE
Sebastian Mon
Driver Flounder Ing CERT# B-00046
LEVEL B
SIGNATURE Flounder Ing
Mickey Mouse Ambulance Signature/Claim Submission Authorization Form
Patient Name: Flash E. Pants Transport Date: 7/1/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample o
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Describe the circumstances that make it impractical for the patient to sign:
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient
X Representative Signature Date Printed Name of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X Patient Signature or Mark Date Witness Signature Date
Describe the circumstances that make it impractical for the patient to sign: immobilized right wrist, recent MVA victim Name and Location of Receiving Facility: Community Hospital, Zootopia Time: 15:25
A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)
My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
X Flounder Ing 7/1/16 Flounder Ing Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
X_____Fergus King________________ 7/1/16 Fergus King, MD
Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.