Downloadable Forms

Patients:
Medicare Redetermination Request Form [PDF]
(to be completed by Medicare recipient if claim is denied by Medicare)

Hospitals/Air Ambulance/Nursing Home Facilities:

Physician’s Certification Statement for Ambulance Transportation [PDF]
(to be completed by physician requesting patient transfer between facilities)

Guarantee of Payment [PDF]
(to be completed by physician/hospital initiating non-emergency patient transfer between facilities)

Credit Card Authorization Form [PDF]
(to be completed by EVAC personnel and faxed to facility that guarantees payment for transfer)