Physician Certification Statement Forms

Medicare, Medicaid, and many other insurance companies require the completion of a Medical Necessity Questionnaire (commonly referred to as a PCS form) for ambulance or wheelchair van transportation. The links below will guide you to the correct form for your transportation needs. You can complete the form on your computer then click print. Once the form is printed it will need to be signed by the individual authorized to do so. Completed and signed PCS forms can be faxed back to us at 603.598.9403 or handed to our staff at the time of pick-up.

 

 

Access Rockingham's Ambulance Medical Necessity form HERE

Access Rockingham's Wheelchair Medical Necessity form HERE

 

 

The form may be completed online, printed and faxed to us at 603-598-9403.

 

 

If you have trouble downloading these forms, or need further assistance completing the forms, please contact our business office by calling 1-800-754-5300.