Forms & Documents – Caregivers | Case Managers

Medicare

Erickson Ambulance Physician’s Certification Statement (PCS)
Written authorization from a physician, physician’s assistant, nurse practitioner, clinical nurse specialist, discharge planner or registered nurse signifying that transport by ambulance is medically necessary and the patient’s condition at the time of transport meets medical necessity requirements. For an ongoing patient (multiple trips), the PCS must be signed by a physician.
Medicare Ambulance Guidelines for Medical Necessity
Medical necessity is established when the patient’s condition is such that the use of any other method of transportation would be hazardous to the patient’s health. This document outlines conditions to be met for medical necessity as well as provides a table reflecting different origination points and coverage.
Medicare Beneficiary Signature
Form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information.
Medicare Coverage of Ambulance Services Booklet
Booklet from Department of Health and Human Services that explains Medicare’s coverage of ambulance transportation, paying for ambulance services, Medicare Rights & Protections and definitions.
Advanced Beneficiary Notice (ABN)
According to Mayo Clinic, an ABN is a written notice from Medicare given to you before receiving certain items or services, notifying you:
•    Medicare may deny payment for that specific procedure or treatment.
•    You will be personally responsible for full payment if Medicare denies payment.
An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. It also offers you the right to appeal Medicare’s decision.
Medicare and You – 2017
Extensive official U.S. government Medicare handbook (160 pages) explaining all aspects of Medicare, enrollment, its coverages, patient rights and fraud protection, long-term care, obtaining more information and definitions.

Other Helpful Forms and Documents

Privacy Practices Notice
Erickson Ambulance’s notice describes how medical information about you may be used and disclosed and how you can get access to this information.

 

 

elite_adminForms & Documents – Case Managers