(a) In this Section: "Ambulance service provider" means a Vehicle Service Provider as defined in the Emergency Medical Services (EMS) Systems Act who provides non-emergency transportation services by ambulance. "Patient" means a person who is transported by an ambulance service provider. (b) If a hospital arranges for medi-car, service car, or ground ambulance transportation of a patient of the hospital, the hospital must provide the ambulance service provider, at or prior to transport, a Physician Certification Statement formatted and completed in compliance with federal regulations or an equivalent form developed by the hospital. Each hospital shall develop a policy requiring a physician or the physician's designee to complete the Physician Certification Statement. The Physician Certification Statement shall be maintained as part of the patient's medical record. A hospital shall, upon request, furnish assistance to the ambulance service provider in the completion of the form if the Physician Certification Statement is incomplete. The Physician Certification Statement or equivalent form is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome; however, a hospital shall provide a copy of the Physician Certification Statement to the ambulance service provider at no charge within 10 days after the request. (c) If a hospital is unable to provide a Physician Certification Statement or equivalent form, then the hospital shall provide to the patient a written notice and a verbal explanation of the written notice, which notice must meet all of the following requirements: (1) The following caption must appear at the beginning of the notice in at least 14-point type: Notice to Patient Regarding Non-Emergency Ambulance Services. (2) The notice must contain each of the following statements in at least 14-point type: (A) The purpose of this notice is to help you make an informed choice about whether you want to be transported by ambulance because your medical condition does not meet medical necessity for transportation by an ambulance. (B) Your insurance may not cover the charges for ambulance transportation. (C) You may be responsible for the cost of ambulance transportation. (D) The estimated cost of ambulance transportation is $(amount). (3) The notice must be signed by the patient or by the patient's authorized representative. A copy shall be given to the patient and the hospital shall retain a copy. (d) The notice set forth in subsection (c) of this Section shall not be required if a delay in transport can be expected to negatively affect the patient outcome. (e) If a patient is physically or mentally unable to sign the notice described in subsection (c) of this Section and no authorized representative of the patient is available to sign the notice on the patient's behalf, the hospital must be able to provide documentation of the patient's inability to sign the notice and the unavailability of an authorized representative. In any case described in this subsection (e), the hospital shall be considered to have met the requirements of subsection (c) of this Section. beginning of the notice in at least 14-point type: Notice to Patient Regarding Non-Emergency Ambulance Services. statements in at least 14-point type: make an informed choice about whether you want to be transported by ambulance because your medical condition does not meet medical necessity for transportation by an ambulance. ambulance transportation. ambulance transportation. transportation is $(amount). the patient's authorized representative. A copy shall be given to the patient and the hospital shall retain a copy.
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