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Provider Type

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

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

Physician Certification Statement Form - Request for Transportation

Use the Physician Certification Statement (PCS) (Medi-Cal PDF) or (CalViva Health PDF) form to document the specific transportation restrictions of a member due to a medical condition, and request non-medical transportation (NMT) or non-emergency medical transportation (NEMT) for Medi-Cal members.

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)
  • 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.


Last Updated: 08/05/2021