Non-Emergency Transport Forms
Advanced Beneficiary Notice (ABN) Hospice Payment Authorization Request Insurance Information Medicaid Authorization Patient/Guardian Consent to Release of Records Physician Certification Statement (PCS) for Medical Necessity Release of Medical Information for Billing PurposesNeeded Non-Emergency Transport Request Forms
Non-Emergency Ambulance Transport Folder Physician’s Certification Statement (PCS) for Medical Necessity * Patient Face Sheet * Patient Medication List * DNR Order (if patient has one)
Other Forms
Facilities Feedback Form Privacy Practice Notice Non-Emgergent Ambulance Dispatch: 970.242.4357 Fax: 970.244.1478
* Incase of an emergency call 911