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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.


Participating physician groups (PPGs) and hospitals must submit a list of their contracted ground emergency medical transportation (GEMT) providers annually. This applies to Medi-Cal providers contracted under a global and dual risk arrangement.

The list is due annually no later than March 31.

The list will help identify non-contracted GEMT providers for automated payments that meet the requirements under the Department of Health Care Services’ GEMT quality assurance fee (QAF) program.

At a minimum, include the following information on the list:

  • Provider name.
  • Provider type (PPG or Hospital).
  • Risk type (Dual or Global).
  • GEMT provider name.
  • GEMT National Provider Identifier (NPI) number.

PPGs and hospitals can send their list to their assigned Provider Relations & Contracting Specialist (PRCS).

Last Updated: 11/02/2021