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Provider Type

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

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-emergency medical transportation (NEMT) for Medi-Cal members. A 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)
  • 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.


Last Updated: 01/10/2023