Transportation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Physician Certification Statement Form - Request for Transportation

Use the Physician Certification Statement Form – Request for Transportation – Health Net (PDF), Physician Certification Statement Form – Request for Transportation – CalViva Health (PDF) or Physician Certification Statement Form – Request for Transportation – Community Health Plan of Imperial Valley (PDF) to document the specific transportation restrictions of a member due to a medical condition, and request non-emergency medical transportation (NEMT) for Medi-Cal members. A physician certification statement (PCS) form is not required for non-medical transportation (NMT).

Providers who may complete and sign the PCS form include:

  • Participating physician group (PPG) or independent practice association (IPA)
  • Doctor of medicine (MD)
  • Registered nurse (RN)
  • Nurse practitioner (NP)
  • Primary care physician (PCP)          
  • Licensed vocational nurse (LVN)
  • Physician assistant (PA)
  • Mental health provider
  • Substance use disorder provider
  • Certified midwife
  • Discharge planner employed or supervised by the hospital, facility or physician’s office where the patient is being treated and has knowledge of the patient’s condition when completing the form.