NON-EMERGENCY AMBULANCE/STRETCHER TRANSPORT REQUEST
PLEASE USE THE AMBULANCE MEDICAL NECESSITY FORM FROM OUR BILLING PAGE
- Completed forms are sent directly to Tim Hagerty by email at thagerty@ultraems.com
- Please make sure the Ambulance Medical Necessity Form is completed and signed by a RN or LPN and a face sheet is given to the ambulance crew at the time of the transport.
- Please confirm transport with Tim Hagerty or dispatch at (800) 943-8367 Extension # 1
* Required Fields – Please complete all required fields before submitting form & enter N/A if there is nothing to add in a field