Allow us to show you and your clients the new standard in medical transport.

Transcription

1 Off Duty Firefighter Medical Transport 411 Merritt St Grand Prairie, Texas Mission Statement: Off Duty Firefighter Medical Transport is a company owned and operated by local firefighters, who are committed to excellence. We strive to continually emplace improved practices, providing our clients the highest standard of care available in our industry. In the interest of patient care, ALL our ambulances are staffed with two Paramedics. We offer our clients: Experienced Paramedics, each having a minimum of 2 years working in a emergency ambulance Advanced Life Support capabilities Emergent and Non-Emergent transports Long distance transfers Professional and friendly care providers The owners and staff of our company have the experience and knowledge necessary to provide the high standard of care our clients deserve. Allow us to show you and your clients the new standard in medical transport.

2 Types of Transports: Local Transport $ Base Fee $8.00 Per mile Long Distance $ Base Fee $8.00 Per Mile Transport (Outside DFW area) Wheelchair Not available Insurance(s): Private Insurance (Blue Cross/Shield, United Healthcare..ETC) Medicare (All parts) Medicaid Private Pay (Due at time of transport) If Client is unsure if their insurance will cover transport, we will take private pay, bill their insurance and if insurance company pays, we will reimburse the client the amount covered by the insurance. Physician Statements: A signed PCS (Physician s Certification Statement) must be obtained for all patients using Medicare/Medicaid. These forms are carried by the ambulance crews, or can be ed to the client to have filled out in advance. These forms are for one time or reoccurring transfers.

3 SECTION I GENERAL INFORMATION Patient s Name: Date of Birth: Medicare #: Transport Date*: Repetitive Transport Expiration Date (Max 60 Days From Date Signed): * This PCS is valid for all trips on the date of transport (i.e., round trips) and for scheduled/repetitive trips in the 60-day range as noted above. Origin: Destination: Is the pt s stay covered under Medicare Part A (PPS/DRG?) YES NO Closest appropriate facility? YES NO If no, why is transport to more distant facility required? If hosp-hosp transfer, describe services needed at destination facility not available at origin facility: If hospice pt, is this transport related to pt s terminal illness? YES NO Describe: SECTION II MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either bed confined or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient s condition. To be bed confined the patient must be: (1) unable to get up from bed without assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair (Note: All three of the above conditions must be met in order for the patient to qualify as bed confined) The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the PHYSICAL OR MENTAL CONDITION of this patient AT THE TIME OF AMBULANCE TRANSPORTATION that requires the patient to be transported on a stretcher in an ambulance and why transport by other means is contraindicated by the patient s condition: 2) Is this patient bed confined as defined above? Yes No 3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*: *Note: supporting documentation for any boxes checked must be maintained in the patient s medical records Contractures Non-healed fractures Moderate/severe pain on movement Danger to self/others IV meds/fluids required Special handling/isolation required Patient is confused, combative, lethargic, or comatose DVT requires elevation of a lower extremity Third party assistance/attendant required to apply, administer or regulate or adjust oxygen enroute Restraints (physical or chemical) anticipated or used during transport Cardiac/hemodynamic monitoring required enroute Orthopedic device (backboard, halo, use of pins in traction, etc.) requiring special handling during transport Unable to maintain erect sitting position in a chair for time needed to transport Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds on buttocks Morbid obesity requires additional personnel/equipment to safely handle patient Other (specify) SECTION III SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance due to the reasons documented on this form. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR (b)(4). In accordance with 42 CFR , the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: AMBULANCE SERVICE AGREEMENTAgree Signature of Physician* or Healthcare Professional Date PRINT NAME AND CREDENTIALS (MD, RN, etc.) *Form must be signed only by patient s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, the form may be signed by any of the following if the attending physician is unavailable to sign (please check appropriate box below) Physician Assistant Clinical Nurse Specialist Registered Nurs e Nurse Practitioner Discharge Planner Thank you for choosing ODF Transport for your Ambulance Transportation Needs

4 Our Service Agreement: The parties to this Ambulance Service Agreement (the Agreement ) are Off Duty Firefighter Medical Transport, DBA ODF Medical Transport, having an office at 411 Merritt St, Grand Prairie, Texas (referred herein as Ambulance Transportation Provider ) and Facility Name: Having and office at Referred to herein as RECITALS 1. (Facility name) is engaged in the business of providing various medical services and skilled nursing services and is duly licensed to do so. Ambulance Transportation Provider is engaged in the business of medical transportation and other services and is duly licensed by the Texas Department of State Health Services to provide ambulance transportation and has trained personnel, who are certified by Texas Department of State Health Services, as Paramedics. 2. (Facility name) desires to obtain certain services of Ambulance Transportation Provider on the terms and conditions stated in this Agreement and Ambulance Transportation Provider desires to provide services on those terms and conditions. 3. In consideration of the mutual promises contained in this Agreement, the parties agree as follows: 4. This Agreement is effective the day of This Agreement expires at midnight on, This Agreement may be renewed by either party giving written notice to the other of its intent to renew the Agreement seven (7) days before the expiration date. 6. Either party may terminate this Agreement at any time by providing at least 30 days written notice of the termination date to the other party. Such termination will have no effect upon the rights and obligations resulting from any transactions occurring prior to the effective date of termination.

5 Ambulance Provider Contact Philip Insco Administrator Off Duty Firefighter Medical Transport, DBA ODF Medical Transport 411 Merritt St. Grand Prairie, Texas Facility contact: Facility Name: Facility Address: Administrator Name: Administrator Signature: Services 7. Ambulance Transportation Provider shall be responsible for furnishing the necessary personnel And, at the request of (Facility name), Ambulance Transportation Provider agrees to provide to the patients of (Facility name), Medical transportation in accordance with all state and local regulations, including franchise rights. First Call Arrangement 8. (Facility name) shall call upon Ambulance Transportation Provider to provide all non-emergency transportation not in violation of local franchise rights. In the event Ambulance Transportation Provider advises (Facility name) that it is temporarily unable to undertake a specific transport, (Facility name) will arrange transportation by another provider. (Facility name) shall advise all staff members and supervisors of the provisions of the paragraph. Ambulance Transportation Provider shall not be in breach of this Agreement nor be liable for damages to (Facility name) if it is unable to undertake a specific transport.

6 Fees and Billing 9. The fees for services provided under this Agreement are stated in the attached schedule 2, which is incorporated herein by reference. 10. Ambulance Transportation Provider shall bill the patient and/or any available reimbursement sources for services, except that in the case of specific services provided by Ambulance Transportation Provider that are covered by applicable laws or regulations-including without limitation, and as an example only, provisions of Section 4432 of the Balanced Budget Act of 1997 and relevant sections of the Code of Federal Regulations and other authoritative documents implementing Section 4432 that require the reimbursement be made to (facility name), Ambulance Transportation Provider shall bill (facility name) for such services. 11. Upon request, (facility name) agrees to provide to Ambulance Transportation Provider information regarding the patients care plan, status and history, to facilitate proper determination by Ambulance Transport Provider whether (facility name) should be billed specific services. To the extent patient consent is required for provision of information to Ambulance Transportation Provider; (facility name) will use its best efforts to obtain that consent. 12. The parties agree to develop a process where they will use their best efforts to work together and consult in good faith expeditiously address patient information and billing issues related to this consent. 13. (Facility name) agrees to pay the fees stated on schedule 2 for services properly billed to it within 30 days of the mailing of an invoice to it for services and to pay simple interest at a rate of 18% per year on any amounts not paid within 30 days of the mailing of the invoice. 14. In the event (facility name) is billed for services it may collect any available co-insurance or deductible. Medical Necessity 15. With respect to any services for which Ambulance Transportation Provider bills (facility name), (facility name) shall be responsible for determining medical necessity of the services and shall pay ambulance transportation provider without regard for weather reimbursement sources challenge the medical necessity of the services, audit claims relating to the services, or make claims against (facility name) relating to the services. With respect to the services for which ambulance transportation provider does not submit a bill to (facility name), ambulance transportation provider releases (facility name) of any responsibility of payment. Physician Certification 16. (Facility name) agrees to comply with any rules or regulations with respect to physician certification for ambulance transportation. In the event the required physician certification is not obtained, ambulance transportation provider reserves the right not to provide transportation. Insurance and Indemnification 17. Each party shall maintain liability insurance in the minimum amounts required by applicable law. Each party agrees to indemnify the other party and its officers, directors, employees, and other agents from all suits, actions, losses, damages, claims, or liability, including without limiting the generality of the foregoing all expenses of litigation, court costs, attorneys fees and expenses, and expert witness fees, arising out of the actions or inactions of such party or its employee or agents in the performance of the agreement.

7 Entire Agreement 18. This agreement, including any schedules hereto, constitutes the sole and only agreement of the parties regarding its subject matter and supersedes any prior understandings or written or oral agreements between the parties respecting this subject matter. Neither party has received or relied on any written or oral representation to induce it to enter into the agreement except each party has relied only on any written representation contained herein. Amendment 19. No agreement or understandings varying or understanding this agreement shall be binding upon the parties unless it is memorialized in a written amendment signed by an authorized officer or representative of both parties. The parties agree that they will not seek any oral amendment of the agreement. Assignment 20. This agreement shall ensure to the benefit of and shall be binding upon successors and assigns of each party. Neither party shall assign their rights or obligations under this agreement without the prior written approval of the other party, except the party may assign this agreement to any person or entity that requires substantially all of that parties business. Legal Construction 21. In the event that any one or more of the provision contained in this agreement shall for any reason be held to be invalid, illegal or unenforceable in any respect such invalidity, illegality, or enforceability shall not effect any other provision and the contact shall be construed as if such invalid, illegal or unenforceable provision had never been contained in it. Force Majeure 22. In the event that the performance by ambulance transportation provider or any of its obligations under the terms of this agreement shall be interrupted, delayed, or hampered by any event, occurrence, situation, of factor beyond its control, it shall be excused from performance for such time as is reasonable necessary for the effect thereof to dissipate. (Facility name) acknowledges occasionally unforeseen increases in demand may make it necessary for ambulance transport provider to request (facility name) obtain services from a back-up provider. Complaints 23. (Facility name) agrees that all complaints or unusual incidents involving personnel or service of Ambulance Transportation provider will be promptly reported to management of Ambulance Transportation Provider and will be described in an incident report detailing the circumstances surrounding the complaint or incident, including their persons or entities involved, date and time of events at issue, and description of events at time. No Agency 24. Thee relationship of the parties is that of independent contractors; neither party shall be deemed to be the agent or partner or fiduciary of the other, nor neither is authorized to take any action binding upon the other.

8 Texas Law 25. The validity of this Agreement and of any of its terms or provisions, as well as the rights and duties of the parties, shall be governed by the laws of the State of Texas. Arbitration 26. Any controversy or claim arising out of or relating to this Agreement, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association under its Commercial Arbitration Rules, and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The arbitration proceedings shall take place in Dallas County. The arbitrator may award to a party who prevails in whole or in part the reasonable attorney s fees, expert witness fees, and other costs and expenses incurred by the part in addition to other relief. Termination of Agreement for Breach 27. Should any party violate any material provision of this agreement, another party may terminate this Agreement by giving written notice that this Agreement will terminate in thirty (30) days unless the defaulting party commences remedying the violation in that time and thereafter diligently pursues the cure of the violation. Any other remedy or remedies under the law for any violation of the terms of this Agreement shall not be limited in any way because of this provision of the exercise of the right conferred in this provision. Miscellaneous 28. Any waiver by a party of its rights hereunder shall not be considered a waiver with respect to any subsequent default or matter, nor shall any usage of trade, course of dealing, practice or performance, or failure to strictly enforce any term, right, obligation or provision of this Agreement by any party be construed as a continuing waiver of any provisions hereunder, unless such waiver is expressed in writing and signed by both parties. AGREED on the day of, 2011 Off Duty Firefighter Medical Transport, DBA ODF Medical Transport By: Philip Insco, EMT-P Administrator Facility Name: Facility Address: Administrator Name: Administrator Signature:

9 Schedule 2 All transports: $ BLS BASE RATE (DFW Area) $ BLS BASE RATE (Long Distance) $8.00 LOADED MILE $50.00 PER HOUR FOR WAIT TIME Additional Charges is ALS services are required. AGREED on the day of, 2011 Off Duty Firefighter Medical Transport, DBA ODF Medical Transport By: Philip Insco, EMT-P Administrator Facility Name: Facility Address: Administrator Name: Administrator Signature:

10 Patient Pre-transport Information Sheet Patient Name: DOB: Contact Information: Primary Health Insurance Name: Policy # Group # Authorization code Supplemental Health Insurance Name: Policy # Group # Authorization code Transport Date: Pick up Time: Appointment Time: Approximate Appointment Length: Transport Pickup Address: Name of Location: Transport Destination Address: Name of Location: Type of Transport: Special Needs Notes: Notes:

11 Service area: Our current service area is within 50 miles of Arlington, Texas. This covers the entire Dallas/Fort Worth Metroplex and surrounding cities