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Get and Sign Pcs Ambulance Form 2017-2022
And without a medical attendant?
If YES
DO NOT order ambulance transportation as it does not meet medical necessity requirements.
2. If NO, describe in detail the medical reason(s) why the patient requires monitoring,
an attendant and/or transport by ambulance. _________________________________
_____________________________________________________________________________________________
Section 3 – HOSPITAL TO HOSPITAL TRANSFERS ONLY
Yes
No
1. Is the patient being transferred to a higher...
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