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Ohio Department of Job and Family Services Ambulette
(1) Patient's Name
(2) Patient's Address
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
(3) Patient's Medicaid Billing Number
(4) Ambulette Medicaid Provider Name
(5) Ambulette Medicaid Provider Number
(6) Date of First Transport
(7) Please certify that ALL of the following criteria have been meet.
Non-Ambulatory - The temporarily patient is disabling non-ambulatory. condition, A which patient is precludes non-ambulatory transportation if they in a have motor a vehicle permanent or or motor carrier that has not been modified or created for transporting a person with a disabling condition.
Wheelchair - Patient is physically able to be safely transported in a wheelchair.
No Ambulance - Patient does not need an Ambulance.
(Check all that apply)
(8) What medical condition requires the patient to use an Ambulette?
Please describe the patient's medical condition that requires the patient to use an Ambulette in terms that an average person could understand. The description of the patient's medical condition should support that all of the criteria in the question above was met.
(9) How long may the patient require an Ambulette for transportation?
Temporary (Not to exceed 90 Days)
Permanent - The patient is expected to need an Ambulette for transport for at least 365 days from the date of the first transport.
Patient is expected to need an Ambulette for transport for how many days from the date of first transport because of the medical condition(s) identified in number 8 and because they meet all criteria in number 7. This certification form is valid for the estimated length of time as designated by the attending practitioner.
(10) Are there any other comments or explanations? (Optional)
(11) Who is the attending practitioner that has ordered the Ambulette transport?
Attending practitioner provider number (Do not use 9111115)
(12) Signature & Professional Letters (i.e. MD, DO, RN, APN, LSW)
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