Medical Facilities — Colorado

Medical Certification for BLS/ALS Transportation

Complete this form to certify and justify the Level of Service (LOS) for a Health First Colorado member requiring BLS, ALS, or stretcher van transportation.

HIPAA compliant • Secure submission • Printable confirmation

Patient / Member Information

First Name*

Last Name*

Date of Birth*

Medicaid / Member ID*

Contact Phone

Is the member homeless?

YesNo

Diagnosis & Medical History

Supporting documentation for transportation limitations

Diagnosis supporting transportation limitations*

Diagnosis Status*

PermanentTemporary

Recent Hospitalizations or Surgeries

Type of Transport Requested

Medical Facility & Provider Information

Facility Name*

Facility Address

State

ZIP

Medical Provider Title*

Medical Provider Name*

NPI Number*

Provider Email*

Provider Phone*

Facility Contact (if different)

Contact Title

Contact Name

Medical Provider Attestation

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil, or both. I certify under penalty of perjury, that I have obtained the information on the form from the patient or their representative, and the information provided is accurate to the best of my knowledge.

I attest that the information provided above is true and accurate to the best of my knowledge.*

All fields marked with * are required