(To
be completed by SNF for each Transport From SNF) |
|
Patient:
DOS: |
| Please answer the following
questions concerning the above named Patient we have been asked to transport: |
1. Is the trip for a
service covered by the current SNF Plan of Care?
_____yes _____no
2. Is the patient within the PPS (part A covered) Period?
_____ yes _____no
3. What type of Service is the patient being transported to the hospital (or other
Facility) to receive? _____ Emergency
_____ Cardiac Catheterization
_____ CT Scan
_____ MRI
_____ Angiography
_____ Lymphatic or Venous Procedure
_____ Tube Insertion/Reinsertion (could not be done at SNF)
_____ X-Ray. If so what type?
_____ Other Diagnostic Test? If so what type?
_____ Surgery. If so, what type?
_____ Radiation Therapy
_____ Hyperbaric Oxygen Therapy
_____ Other. Please Specify: |
______________________
Signature |
___/___/___
Date |
