Ambulance Request Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Date of Service* MM slash DD slash YYYY Member's Name* First Last Error Message Ambulance Company InformationAmbulance Company NPI* 10 digitsAmbulance Company Name* Error Message Ambulance Company Phone #*Ambulance Company Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationHCPC Code(s) (Click + or - at the right to add up to 5 HCPC Codes)*HCPC CodeUnits Example HCPC code: S1234 with modifier: S1234 U1Primary Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Who Requested Ambulance* Place of Origin*(e.g. name of hospital, group home, etc) Destination*(e.g. name of nursing home, member’s home, etc) Medical Necessity InformationIf available, please indicate treating clinician who provided the information and their location. If no information available, please leave blank and Neighborhood will obtain.Clinician Name Clinician Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical Condition(s) which prevents safe transportation by any other means - Check each applicable conditionConfined to bed? (unable to sit, stand or walk (this does not apply to being on bed rest))*Confined to bed? (unable to sit, stand or walk (this does not apply to being on bed rest)) *YesNoCheck all that apply:*Member requires monitoring by a trained staff because: Airway Monitoring Cardiac Monitoring Life Support Ventilator Dependent Comatose Poses immediate danger to self or others Active Seizures Medically unstable Decreased level of consciousness Requires isolation due to disease or other exposure Other Please Specify (Requires isolation due to disease or other exposure):* Please Specify (Other):* Is this transport result of a hospital discharge?*Is this transport result of a hospital discharge? *YesNoDoes the Ambulance have the necessary equipment and supplies to address the needs of the member?*Does the Ambulance have the necessary equipment and supplies to address the needs of the member? *YesNoRequest Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited Request)Signature Date* CommentsCAPTCHA PhoneThis field is for validation purposes and should be left unchanged.