useful forms and documentation

downloads

Here at Medics First, we know that it can be a time-consuming process to find and fill out patient related forms. That's why we've supplied links below to a few of our most commonly requsted forms so that you can fill them out at your convenience. Please don't hesitate to contact us with any questions you may have.

 

billing

Financial Assistance Program

This program provides discounts on transportation charges for patients that meet pre-determined household income and family size requirements.

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Proceso de solicitud para el Programa de asistencia financiera

Medical Records Request

As a patient, you have the right to access, copy or inspect your protected Health Information, or PHI, in accordance with federal law.

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Solicitud de registros medicos del paciente

Bill Your Insurance

We offer a courtesy billing service. This service submits a bill to your insurance company for services rendered on your behalf.

Notice of Privacy Practice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

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Notificación de prácticas de privacidad

Medicaid / medicare

MEDICARE Physician Certification Statement

The Physician Certification Statement (PCS) Form is written authorization from a Physician, Physician's Assistant, Nurse practitioner, Clinical Nurse Specialist, Discharge Planner or Registered Nurse signifying that transport by ambulance is medically necessary and the patient’s condition at the time of transport meets medical necessity requirements.

MEDICAID Transportation Requirements

Not all ambulance service is covered by Medicare. In order to be covered, the ambulance service must be necessary and reasonable.

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Manual de servicios de transporte

MEDICARE Transportation Requirements

Not all ambulance service is covered by Medicare. In order to be covered, the ambulance service must be necessary and reasonable.

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Requisitos MEDICARE Transporte

MEDICARE Appeal Request

If you do not agree with the determination decision on your claim and would like to file an appeal with Medicare, use this form.

IPT Transport Request

Behavior Health Service Transport Request Form

Illinois Patient Transport (IPT), transports involuntary patients, regardless of a client’s ability to pay. Involuntary transports are funded when utilizing Illinois Patient Transport, through a contract with the Illinois Department of Human Services.

To request a transport, FAX the following documents to 309-494-6227:

  • Petition & Certificate (or Court Order)
  • Hospital Face Sheet
  • Illinois Patient Transport Request Form
Complete the transport request by contacting our Call Center at 309-999-4040, open 24/7 to gather information regarding the transport.

Transportation for voluntary and juvenile patients (12 and older) may be arranged on a case by case basis with a guarantee of payment or, for a better rate, your facility may wish to contract directly with Illinois Patient Transport.