Ambulance Request Form Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Date of Service* MM slash DD slash YYYY Member's Name* First Last Error Message Ambulance Company InformationAmbulance Company NPI* 10 digitsAmbulance Company Name* Error Message Ambulance Company Phone #*Ambulance Company Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationHCPC Code(s) (Click + or - at the right to add up to 5 HCPC Codes)*HCPC CodeUnits Example HCPC code: S1234 with modifier: S1234 U1Primary Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Type of Ambulance Needed*Type of Ambulance Needed *Stretcher AmbulanceWheelchair AmbulanceWho Requested Ambulance* Place of Origin*(e.g. name of hospital, group home, etc) Destination*(e.g. name of nursing home, member’s home, etc) Medical Necessity InformationIf available, please indicate treating clinician who provided the information and their location. If no information available, please leave blank and Neighborhood will obtain.Clinician Name Clinician Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical Condition(s) which prevents safe transportation by any other means:* Please indicate the purpose of transfer:*Check all that apply:* Confined to bed (unable to get out of bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair) Unable to safely sit upright while in a wheelchair Can tolerate a wheelchair but is medically unstable Requires specialized monitoring of mental status, airway monitoring, and/or cardiac monitoring Requires isolation due to disease or other exposure Is a danger to self or others Other Other Reason*All three (3) of the following criteria must be met for all non-emergency wheelchair ambulance transportation to be considered medically necessary:* The transportation is for the member to receive medically necessary care The member can tolerate a wheelchair but has no capacity to mobilize outside of the house to the curb for EDS transportation pick up There is no caretaker/family available to transport member or to bring them to the curb Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited Request)Signature Date* CommentsCAPTCHA