Dispatch online 24/7
Patient Resources
Patient resources
Clear answers,
before every ride.
Plain-language guides to medical necessity forms, Medicare coverage, scheduling and what to expect on the day of transport, written for patients, families and care teams.
Forms & notices
The paperwork,
made simple.
Blank copies of the forms you’re most likely to need. Download and print them, or apply online — here’s what each one is and what happens next.
PCS / PMNF
Medical Necessity Form
A Physician Certification Statement (PCS), ours is called the PMNF, is completed by the patient’s medical team. It explains why the patient needs a stretcher ambulance instead of a car or wheelchair van. Medicare and most insurers require one for non-emergency trips.
How it works
1
Download the PMNF
Print the form below, or call and we’ll send it to your facility.
2
The medical team completes it
The attending physician describes the patient’s condition, then signs and dates it. For one-time trips, if the physician isn’t available, a qualified nurse, PA, NP or discharge planner may sign.
3
Send it to Tri State EMS
Fax it to 610-549-7449 or email Dispatch@tristateems.com before the trip.
4
Renew it for recurring trips
For repeat trips such as dialysis, the form must be signed within the 60 days before each ride.
Original Medicare
Advance Beneficiary Notice (ABN)
An ABN (form CMS-R-131) is a notice we give before a non-emergency trip when we believe Medicare may not pay for it. It lets you decide, before the ride, whether to go ahead and accept the cost if Medicare says no.
Your three choices
1
Ride, and bill Medicare
We send the claim to Medicare. If it’s denied, you’re responsible for payment, and you keep the right to appeal.
2
Ride, but don’t bill Medicare
You pay for the trip yourself. No claim is sent, so there’s nothing to appeal.
3
Don’t take the ride
You decline the trip and aren’t responsible for payment. No claim is sent.
If an ABN applies to your trip, we’ll give it to you to review and sign beforehand. Questions? Our billing team is happy to explain.
Employment Application
CAREERS
Want to join our crew as an EMT, ambulance operator or dispatcher? Our application takes a few minutes online — no printing needed.
Medicare coverage
What Medicare covers
and what it doesn’t.
Medicare Part B covers ground ambulance transportation when traveling in any other vehicle could endanger your health. Non-emergency trips follow stricter rules. Here’s a simple overview.
Usually covered
Trips where riding in a car or wheelchair van could endanger the patient’s health
Medically necessary trips to or from a hospital, critical access hospital or skilled nursing facility
Dialysis trips for patients with end-stage renal disease who meet the criteria
Non-emergency trips ordered by the patient’s doctor when an ambulance is medically necessary
Usually not covered
Patients who can safely travel by car, taxi or wheelchair van
Trips for convenience or personal preference
Routine visits to a doctor’s office
Wheelchair van rides, which Original Medicare doesn’t cover
Trips without the required medical necessity paperwork
What you pay
20%
of the Medicare-approved amount, after you meet the yearly Part B deductible.
A Medigap or secondary plan may cover some or all of your share.
Medicare Advantage plans set their own copays and may require prior authorization.
What “bed-confined” means
It’s one of the main factors Medicare considers, and all three of these must apply:
01
Can’t get up from bed without help
02
Can’t walk
03
Can’t sit in a chair or wheelchair
A patient who isn’t bed-confined may still qualify if their medical condition makes an ambulance the only safe way to travel.
Recurring trips & prior authorization
Medicare reviews repeat, scheduled trips in advance. That means three or more round trips in 10 days, or at least one a week for three weeks, such as trips for dialysis or cancer treatment.
Up to 40
round trips per approval, covering up to 60 days
60 days
the longest a signed form stays valid for recurring trips
Call us and we’ll walk you through what’s needed to get recurring trips approved.
Medicare ambulance guides
Free PDF guides that explain when Medicare covers ambulance transport and what’s required.
Summarized from Medicare.gov and CMS rules (42 CFR 410.40). Coverage decisions are made by Medicare or your health plan, not by Tri State EMS.
How transportation works
From first call
to safe arrival.
Every trip follows the same careful process, whether it’s a hospital discharge, a dialysis appointment or a long-distance transfer.
01
Request
Call dispatch 24/7 or send an online request with the patient’s details, pickup and destination.
02
Verify
We review the trip, check insurance and confirm any paperwork, such as a medical necessity form or prior authorization.
03
Confirm
Dispatch confirms the date and pickup time with you, the patient or the facility.
04
Pickup
Our EMT crew arrives with a powered stretcher, plus a powered stair chair when needed, and safely moves the patient to the ambulance.
05
Ride
The crew monitors and cares for the patient throughout the trip, keeping them safe and comfortable.
06
Arrive & bill
We hand off to the receiving team, then bill insurance. Any remaining balance can be paid online.
How to schedule
Booking takes
just a few minutes.
Patients, families and facilities all book the same way. Choose whichever option is easiest for you.
Checklist
Have this ready when you book
Patient’s full name and date of birth
Pickup address and destination, including room or unit
Date, pickup time and any appointment time
Insurance details, such as Medicare, Medicaid or plan ID
Patient’s weight and mobility, plus oxygen or other special needs
Stairs, elevators or tight spaces at either location
Whether a return trip is needed
Signed medical necessity form (PCS), if you have it
A contact name and phone number
Booking recurring trips, like dialysis? Share the full schedule when you book so we can plan every ride.
Stretcher vs. wheelchair
Stretcher ambulance
transportation only.
Wheelchair vans and stretcher ambulances serve very different patients. Tri State EMS provides stretcher ambulance transportation only. We don’t offer wheelchair van service.
What we provide
Stretcher ambulance
For patients who need to lie down, or need care and monitoring during the ride.
Who it’s for
Bed-confined patients, or anyone who can’t sit up safely for the trip
Crew
Certified EMTs who monitor and care for the patient
Equipment
Powered stretcher, powered stair chair, oxygen and medical supplies
Position
Lying flat or reclined, secured on the stretcher
Insurance
Often covered by Medicare and other plans when medically necessary
Not offered
Wheelchair van
For patients who can sit upright safely for the whole trip.
Who it’s for
Patients who can stay seated in a wheelchair for the full trip
Crew
A driver, typically without medical training
Equipment
Wheelchair lift or ramp and securement straps
Position
Seated in their own wheelchair
Insurance
Not covered by Original Medicare; some Medicaid and Medicare Advantage plans cover it
Not sure which one you need? Call dispatch. We’ll help you decide, and let you know if a wheelchair van is the better fit.
Questions
Good to know
before you book.
Quick answers about rides, forms and coverage. Still unsure? Our team is available 24/7.
Do you provide wheelchair van transportation?
No. Tri State EMS provides stretcher ambulance transportation only, with EMTs on every trip. If the patient can sit safely in a wheelchair for the whole trip, a wheelchair van service may be a better fit.