Transportation Flow Chart
In an effort to assist in choosing the appropriate type of transportation service, we are proud to provide this transportation flowchart to help with that decision. Please use this chart as a reference guide and if you need assistance please call us anytime at (317) 548-4044. Click for a downloadable chart.
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Non-Physician Certification Statement Form
Physician's Certification Form (PCS) is a written authorization form from a Physician, Physician's Assistant, Nurse practitioner, Clinical Nurse Specialist, Discharge Planner, Registered Nurse, Licensed Practical Nurse, or Case Manager that signifies that transportation by an ambulance is medically necessary. In order for Midwest Ambulance Service to transport Medicare patients we require a patient's PCS form at pick up.
Repetitive Medical Necessity Form
Like the Physician's Certification Statement, a Repetitive PCS form allows transportation by an ambulance for three or more times during a 10-day period or at least once per week for at least three weeks. The Repetitive PCS must by signed by a Medical Doctor and given to the ambulance team upon arrival.
Request for Ambulance Transportation for a Beneficiary in a Medicare Part A Stay
An SNF can provide this type of notification to an ambulance service transporting a beneficiary. Reflecting consolidated billing rules, this notice lays out the types of ambulance trips for which the ambulance service should bill Medicare directly and the types of ambulance trips which would require payment by the SNF to the ambulance service. Midwest Ambulance asks for their partners to fill out this form when transporting a beneficiary under a Part A Stay.
HIPAA Patient Privacy Notice
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all health care providers to distribute notices explaining individual rights with respect to their personal health information and privacy practices. Our notice can be accessed by clicking the download button below. Please feel free to contact us any time regarding your private health information and your privacy rights.
Indiana Physician Orders for Scope of Treatment (POST)
"The Indiana POST Program is designed for persons with advance chronic progressive disease, frailty, or terminal conditions. These are persons for whom the physician would not be surprised if they died within the next 12 months because of their advance disease. Persons with these life-limiting conditions experience diminished benefits from treatments and increased burden as their condition progresses. The centerpiece of the program is the POST form, which documents an individual's treatment preferences in the form of medical orders that are easily understood by healthcare providers. The POST form is designed to transfer with an individual throughout the healthcare system to ensure treatment preferences are honored across all care settings.
A DNR or Do Not Resuscitate form and a POST form have differences and similarities. The DNR must be made in conjunction with a physician and the individual or the individual's representative (legal guardian, court appointed representative, formal Healthcare Representative, or Power of Attorney) in order to state that an individual is terminally ill and would not be expected to recover well from cardiac arrest and, therefore, resuscitation efforts should be withheld. Different DNR forms are used within facilities (extended care facilities and hospitals) versus the out of hospital DNR. This has created confusion and often an inability to honor DNR forms by out of hospital providers - specifically EMS. The Out of Hospital DNR (OHDNR) must contain the individual's name, date of the DNR, the words Do Not Resuscitate and Physician signature. A POST form has one section dedicated to the Code Status or DNR preferences (Section A). The remainder of the form is dedicated to outlining specific treatment guidelines. (example: I do want artificial 6 nutrition; I do not want transported to the hospital; etc.) The POST form must also be executed in conjunction with a physician and the individual or the individual's Authorized Representative, Guardian or Power of Attorney. The POST form is not intended for persons with a long life expectancy and should be revisited if a person's medical situation changes."-From the Indianan EMS POST Educational Packet (https://www.in.gov/dhs/files/Indiana_EMS_POST_Educational_Packet.pdf)
As EMS providers, we are legally bound to honor POST orders. Below is a link to the POST form, which can be filled out, signed, and given to our EMS crews so they will know which treatments to provide during transport in our ambulances.