ADVANCE EMS Text Size:+- (361)857-2059 5018 Chancellor Row Corpus Christi, TX 78416 Home About Us Services Career Opportunities Request a Quote Transportation Forms Facebook Twitter LinkedIn Medicare Certificate of Medical Necessity CMN/PCS Form: The CMN (Certificate of Medical Necessity) is for patients who have Medicare and Medicare Advantage/Replacement Programs. This form is required for all non-emergency transports. The form must have the patients Full Name, DOB and Date of Trip. You must also check and document all listed descriptions that apply for the patient at the time of service. The form can be completed by the following personal: Attending Physician, Primary Care Physician, Physician Assistant, Nurse, Nurse Practitioner, or Discharge Planner. The healthcare professional must print their name, sign and date the form. **Ambulance transportation for dialysis treatment requires the CMN to be completed by a Physician. Examples of non-emergent transports requiring a CMN include: discharges from hospital to nursing home, home, or long term acute care facilities, etc. Medicare Certificate of Medical Necessity Form Medicaid Prior Authorization Form: The Medicaid Prior Authorization form is for patients who have Medicaid. This form is required for all non-emergent transports. The 1st Form: Non-emergency Ambulance Prior Authorization Request will allow for a 2-60 day authorization. The 2nd Form: Non-emergency Ambulance Exception will allow up to 180 days of authorization. Medicaid will only respond via fax so it is very important that you check you faxes every day. Examples of non-emergent transports requiring a Prior Authorization include: doctor visits, outpatient medical treatment, discharges from hospital to nursing home, home, or long term acute care facilities, etc. Medicaid Prior Authorization Forms Request a Quote Transportation Forms Employee of the Month COPYRIGHT © 2014 ADVANCE EMS, ALL RIGHTS RESERVED ELLEN MAE IS A WORDPRESS THEME BUILT ON GENESIS

ADVANCE EMS Text Size:+- (361)857-2059 5018 Chancellor Row Corpus Christi, TX 78416 Home About Us Services Career Opportunities Request a Quote Employee Of The Month Facebook Twitter LinkedIn We value all our employees, every month there is an employee that goes above and beyond, this month the employee name is: Richard Sepeda Request a Quote Transportation Forms Employee of the Month COPYRIGHT © 2014 ADVANCE EMS, ALL RIGHTS RESERVED ELLEN MAE IS A WORDPRESS THEME BUILT ON GENESIS

ADVANCE EMS Text Size:+- (361)857-2059 5018 Chancellor Row Corpus Christi, TX 78416 Home About Us Services Career Opportunities Request a Quote Request a Quote Facebook Twitter LinkedIn Contact Full Name:* Contact Phone and Email:* From and To Address:* Relationship: Date Range: Transport Type:* Ground Ambulance Air Ambulance Wheel Chair Transport One Way Round Trip Submit Reset Request a Quote Transportation Forms Employee of the Month COPYRIGHT © 2014 ADVANCE EMS, ALL RIGHTS RESERVED ELLEN MAE IS A WORDPRESS THEME BUILT ON GENESIS