25-908 Action Needed: Submit a PCS Form for NEMT for Medi-Cal Members
Date: 09/02/25
The form helps ensure correct level of service.
It is crucial that physicians and other providers submit a Physician Certification Statement (PCS) form when requesting Non-Emergency Medical Transportation (NEMT) transportation for Medi-Cal patients. The Department of Health Care Services requires use of the form.
Examples of NEMT services include:
- Wheelchair van
- Gurney/stretcher van/litter van
- Ambulance levels of service
- Air transport
What you need to do
For members with a CalViva Health Medi-Cal plan, a signed PCS form is required for certain transportation services.
Refer to the links below to download the form, then fill it out and submit it to the Health Net Care Ride Unit to obtain authorization. If the form is not completed, authorized as applicable and on file, the member may not be able to receive needed transportation until the completed form is received. Avoid this delay, which could impact member care.
What is a PCS form?
The PCS form enables physicians to document a member’s medical condition and any transportation limitations. This information helps determine the most appropriate mode of transportation. Some transportation levels require prior authorization via a faxed PCS form.
When is a PCS form required?
Refer to the flyer, 25-751, How to Help Members Access Transportation for Health Care Services (PDF), to request transportation and see services that require a PCS form. Reassess the member’s medical need for medical transportation when prior authorization expires. If they still qualify, reapprove the transportation and submit a new PCS form. Authorization may be granted for up to 12 months.
Download the PCS CVH Form (PDF) or from the Provider Library under Medi-Cal > Forms and References.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.