Grand Junction Fire Dept. EMS Division

Non-Emergency Transports

Non-Emergency Transport Process Information

• Non-Emergency Transport Process Brochure
• Facilities' Feedback Form

Non-Emergency Transport Forms:

• Advance Beneficiary Notice (p.1)
• Notice of Non-Covered Service Forms (p.2)
• Hospice Payment Authorization Request Form
• Insurance Information Form
• Medicaid Transportation Confirmation Form
• Patient/Guardian Consent To Release of EMS Records Form
• Physician Certification Statement for Medical Necessity
• Release of Medical Information for Billing Purposes
• Notice of Privacy Practice

Forms Needed for EVERY Non-Emergency Transport Request:

• Form for Non-Emergent Ambulance Transport Folder
• Physician's Certification Statement for Medical Necessity
• Patient Face Sheet
• Patient Medication List
• DNR Order (if patient has one)