PCS Form- Provider’s Certification Statement/Certificate of Medical Necessity: This is Med-Care’s form which must be filled out accurately & completely for every covered ambulance transportation. This is not a common occurrence. 

Signature Attestation CMS: In rare instances, we must have a physician, RN, or other healthcare professional fill out & return this form before we may bill for services. 

Advance Beneficiary Notice (ABN): Some patients must fill out this form and have it on file with our office before a transport can occur. If any specific transport requires this form, our dedicated Customer Service Representatives or Billing Specialists will let you know. This form is not mandatory for most trips, but is a requirement for some. 

Recurring Payment Form: If you have received a bill in the mail and you are facing financial hardships, it is important that you call our office and speak with one of our billing specialists. For your convenience, we do set up recurring payment plans for all of our patients who are experiencing financial difficulties in accordance with CMS and FTC guidelines. 

New Payment Agreement Form: Occasionally, we receive requests from a facility with whom we do not have a business relationship. We are happy to oblige, provided we have a signed agreement in the event an insurance company refuses to reimburse. This is not a common requirement.

Request to Disclose Records: This is MedCare’s form which authorizes us to release a patient’s records. Under Federal and Maryland Law, health information must remain confidential but is available to the patient and certain other parties (such as an attorney’s office, a physician’s office, etc). If you are requesting a patient’s records, you must fill out this form & fax it back to 443-275-1094. Forms will be verified & researched before ANY information is released. We strongly suggest having the patient or patient’s POA sign this form. If the patient or POA is unable to sign and you have a generic release already signed, please include a copy of that when faxing the request. Please note that MedCare Transportation considers records requests & confidentiality extremely seriously, and information will only be released on a case-by-case basis and ONLY the requested information. There is also a non-refundable fee assessed for the records which will be communicated prior to the release.

MCT Employment Verification Release: This is MedCare’s Employment Verification Form. If you need to verify somebody’s employment, you must fax a completed request to our office at 443-275-1094.

Maryland MOLST Form: MOLST is an acronym for the Maryland Medical Orders for Life-Sustaining Treatment Form. For ambulance transportation, this form should be filled out and presented to the EMTs prior to transporting.

MCT Ambulance Signature Form: This form is for our ambulance teams in the event their computer/tablet isn’t functioning correctly.

Transportation Request Form: This form is mostly for our contracted facilities. Print the form, fill it out, and fax it to us at 443-275-1094. Please note that faxing us a form does NOT mean the requested appointment time is available: this is simply a form notifying us of the request and providing us with the information we need to process the request. Once faxed to us,  please call us at 410-375-6915 to ensure we’ve received your request(s).

Standing Order Request: This form is for our contracted facilities. If you have a patient who requires transportation on a regular, recurring basis (such as dialysis and/or radiation therapy), fill out & fax this form along with all other required paperwork to our office as soon as possible.

Dialysis-Repetitive Transport Regulations: as published by CMS.

Baltimore County MA Form- Wheelchair and Sedan: This form must be accompanied with all requests for wheelchair or sedan transportation if the patient to be transported has Maryland Medical Assistance. Included in this form are the instructions for completion. Please follow those instructions and submit all paperwork to the correct recipients.

Baltimore County MA Form for AMBULANCE Transportation: This form must be accompanied with all requests for ambulance transportation if the patient to be transported has Maryland Medical Assistance. Included in this form are the instructions for completion. Please follow those instructions and submit all paperwork to the correct recipients.

Baltimore County Transfer and Discharge Form: This form must be accompanied with all transfer/discharge transportation requests  if the patient to be transported has Maryland Medical Assistance. Included in this form are the instructions for completion. Please follow those instructions and submit all paperwork to the correct recipients.

Baltimore City MA Form- AMBULANCE: If your bed-confined Medical Assistance patient is physically located in Baltimore City at the time of the transport, you need this form.

Baltimore City MA Form- Wheelchair & Mobility: If your Medical Assistance patient needs wheelchair transportation AND is physically located in Baltimore City at the time of the transport, you this form.

APPLICATION FOR EMPLOYMENT FORM:  in the event you wish to fill out the paper version (we strongly recommend you click HERE to fill it out online), click on this form. When you fill it out, you can print it & mail it, drop it off, or e-mail it to mctinfo@medcaretransportation.com . Keep in mind, the fastest way for us to receive your application is to fill it out online & submit it through the website. 

HIPAA Statement: Here is the PDF version of our HIPAA Statement.

Website Privacy Policy: Here is the PDF version of our website’s Privacy Policy