- Participating Physician Groups (PPG)
- Los Angeles
- San Diego
- San Joaquin
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.