Facility Transport Forms

(For Use by Health Care Facilities Only)

Medicare, Medicare HMO, Medicaid, Medicaid HMO and BCBS require a Physician Certification Statement (PCS) form to be completed for all non-emergency ambulance transportation.

A completed PCS form is required for each trip to and from the destination.

Please click on “Download PCS Guide” below to view instructions on how to complete a PCS form appropriately.

If you have any questions please call 800-499-9316 to speak with a Customer Accounts Specialist.