Medical-Certification-for-BLS-Or-ALS-Transportation

Medical Certification for BLS/ALS Transportation

The member's medical provider must complete this form to verify the medical necessity of Basic Life Support (BLS) or Advanced Life Support (ALS) transportation.

Patient Information

First Name

Last Name

DOB

Member Id

Medical Facility Information

Name

Address

State

Zip

Medical Provider Title

Medical Provider Name

Contact Title

Contact Name

Contact Phone

(123) 123-1234

Contact Email

Type of Transport Requested

ALS

BLS

Stretcher Van

Reason Patient requires BLS or ALS transportation

Term Of Verification

Indefinite Term ?

NoYes

From

Medical Provider Attestation

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil, or both. I certify under penalty of perjury, that I have obtained the information on the form from the patient or their representative, and the information provided is accurate to the best of my knowledge.

Title

Name of Facility Staff

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