DOCUMENTS & FORMS

Forms

When preparing for ambulance transport from Chicago Ambulance Alliance, please ensure that you have downloaded and completed the following paperwork.

To download each form, please click the underlined name in the form descriptions! Or find the most up-to-date forms here, and click the underlined name to download.

Please contact us at 708.532.0088 with any questions or concerns.

Medical Necessity & Coverage Guidelines

Medicare, Medicaid, and most commercial insurances require that "other modes of transportation be contra-indicated."  This means that the healthcare provider scheduling the transport must provide documentation that describes why the patient cannot safely be transported by any other means. In addition to meeting one of the most common criteria listed below, the certifying professional must provide a medical diagnosis that explains why the patient meets the criteria

If you have any questions regarding medical necessity or ambulance coverage criteria, please do not hesitate to contact our communications center, where our customer support team can assist you with determining whether your patient meets the requirements. Please understand that the relevant insurance providers make the final coverage decisions.

AMBULANCE CRITERIA

  • Is the patient "bed confined"?

  • Isolation Precautions

  • Oxygen

  • Ventilation/Advanced Airway Management

  • Suctioning

  • Intravenous Fluids

  • Chemical Restraints or Physical Restraints

  • One-On-One Supervision

  • Specialized Monitoring

  • Special Handling/Positioning

  • Clinical Observation

  • Unable to maintain a safe sitting position for the length of the time of transport

  • Stairs/Lifting

MEDICAR CRITERIA

  • Requires assistance navigating stairs or getting into wheelchair

  • Ambulatory - Can travel safely using fixed route transportation/ Unable to travel by fixed route

  • Uses transfer wheelchair - able to step into regular car

  • Needs Lift: Unable to step into regular car wheelchair bound

  • Dementia/Mental health history

  • Has contractures: Arms Legs Trunk

  • Ambulatory - does not use a walking device like a walker, cane, etc./ Uses walking device

  • Unable to travel alone, needs attendant(s)

  • Obese - weight lbs.

  • Requires oxygen and is able to self-administer or uses oxygen as needed (pm)

  • Paralysis: Hemi, Para, Quadra

  • Assistance needed to/from wheelchair

Insurance Links

Prepare for ambulance transport from Chicago Ambulance Alliance by reviewing your coverage/services offers with your insurance provider.

To visit each page, please click the underlined name in the form descriptions!

Please contact us at 708.532.0088 with any questions or concerns.

Have questions? Talk to an account representative!