Non-Emergency Ambulance Transportation

Non-Emergency Ambulance Transportation

You can use the printable clinical templates and suggested clinical data elements (CDEs) for the order / physician certification statement, progress note, and prior authorization request to assist with documenting your medical records to support the need for Non-Emergency Ambulance Transportation (NEAT).

Health IT Vendors: To use the suggested CDEs, download or print and use as guidance in creating or enhancing existing electronic clinical templates within your electronic health record (EHR) system.

Providers: To use a printable clinical template, download and/or print the template, complete as applicable and file in the patient’s medical record.

Type of Documentation Download
Order / Physician Certification Statement (PCS)  
Non-Emergency Ambulance Transportation Order-PCS CDEs (PDF) Draft R1.0e 7/20/2018
  Template (PDF) Draft R1.0e 7/20/2018
Progress Note  
Non-Emergency Ambulance Transportation Progress Note CDEs (PDF) Draft R1.0e 7/20/2018
  Template (PDF) Draft R1.0e 7/20/2018
Prior Authorization (PA) Request  
Non-Emergency Ambulance Transportation PA Request CDEs (PDF) Draft R1.0e 7/20/2018
  Template (PDF) Draft R1.0e 7/20/2018


We want to hear from you! Email us your comments and suggestions about the draft templates and CDEs.


Page Last Modified:
09/06/2023 04:51 PM