Facility Forms & Documents

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Case Managers

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 using any other transportation method would be hazardous to the patient’s health. This document outlines conditions to be met for medical necessity and provides a table reflecting different origination points and coverage.

Medicare Beneficiary Signature

The form is used to advise Medicare of the person you have chosen to access your personal health information.

Medicare Coverage of Ambulance Services Booklet

Booklet from the Department of Health and Human Services explains Medicare’s ambulance transportation coverage, 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 allows you 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 – 2022

The extensive official U.S. government Medicare handbook (128 pages) explains all aspects of Medicare, enrollment, coverages, patient rights and fraud protection, long-term care, and obtaining more information and definitions.

Medicaid

Medicaid Ambulance and Medicar Coverage Guidelines

The document provides guidelines for ambulance and medicar coverages by Medicaid, including prior approvals, approval procedures, and a table reflecting different origination points and coverage.

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Non-Emergency Transportation Prior Approval Program (NETSPAP)

Certification of Transportation Services (CTS) – entry ready

The form must be completed and signed by a doctor or licensed professional to transport non-emergency medical appointments upon request by First Transit.

Netspap Single Trip Form

A facility must complete the form for a single non-emergency trip.

Netspap Standing Prior Approval Form

A facility must complete the form for prior authorization of non-emergency transportation (ongoing).

First Transit Trip Request Instruction in English

The document provides detailed trip request instructions from First Transit.

First Transit Trip Request Instruction in Spanish

The document provides detailed trip request instructions from First Transit.

Psychiatric Services Treatment Plan Form – for CAP/GAP Providers

The referring and direct service provider must sign the form developed for non-emergency transportation.

Psychiatric Services Treatment Plan Form – for Provider Type 36 Community Mental Health Services

The form must be completed, dated, and signed by the LPHA designated for the participant needing non-emergency transportation services.

Medical Certification for Non-Emergency Ambulance (MCA)

The form is required by law when an Illinois Medicaid participant is discharged from a hospital and is transported via ambulance. A patient’s condition must meet medical necessity criteria to be transported via ambulance, and the treating provider must certify that such criteria are met.