26-953 PCS Form Required to Authorize NEMT Services for Medi-Cal Members

Date: 07/31/26

Submit a PCS form to avoid authorization delays or denials

A completed and signed Physician Certification Statement (PCS) form is required to authorize Non-Emergency Medical Transportation (NEMT) services for Medi-Cal members.

Missing or incomplete forms will result in authorization delays or denials.

 How to submit a PCS form

1  Access the PCS form.

• Download the form at PCS HN Form (PDF).
• Or access the Medi-Cal Provider Library > Forms and References.

2  Complete and sign the form.

3  Submit the form. Fax the completed form to the Health Net Care Ride Unit at 833-701-0051 to obtain required authorization before scheduling transportation.

NEMT services requiring a PCS form

• Wheelchair van
• Gurney, stretcher van or litter van
• Ambulance (all levels of service)
• Air transport

Authorization and renewal

• Authorizations are valid for up to 12 months
• Reassess medical necessity upon expiration
• Submit a new PCS form if services continue to be required

 

This information applies to Physicians and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.