Emergency Medical Condition Certification Form
This form, provided by the New York State Department of Health, is used to certify treatment of an emergency medical condition for Medicaid eligible individuals. It must be completed by a treating physician and includes sections for patient information, diagnosis, treatment details, and physician certification. Instructions for completing and submitting the form are also provided.
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How do I fill this out?
To fill out this form, you'll need to complete sections for patient information, diagnosis and treatment details, and physician certification. Ensure that the treating physician signs the form. Follow the instructions provided carefully to ensure accuracy.
How to fill out the Emergency Medical Condition Certification Form?
1
Read the definition of an emergency medical condition.
2
Fill out patient information fields.
3
Complete diagnosis and treatment details.
4
Ensure treating physician certifies and signs the form.
5
Submit the form to the local Department of Social Services.
Who needs the Emergency Medical Condition Certification Form?
1
Patients requiring emergency medical treatment under Medicaid.
2
Physicians treating emergency medical conditions for Medicaid patients.
3
Hospitals and medical facilities providing emergency services to Medicaid patients.
4
Medicaid applicants seeking coverage for emergency medical treatment.
5
Social services workers processing Medicaid emergency treatment eligibility.
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1
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2
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3
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4
Add or modify any additional required fields.
5
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What are the instructions for submitting this form?
To submit this form, print it out and complete all required sections. The treating physician must sign the form where indicated. Submit the completed form to the local Department of Social Services. Keep a copy of the form for your records. For any questions regarding submission, please contact your local Department of Social Services.
What is the purpose of this form?
The purpose of this form is to certify the treatment of an emergency medical condition for Medicaid eligible individuals. It ensures that only those treatments meeting the federal definition of an emergency medical condition are covered. The form must be completed by the treating physician and submitted to the local Department of Social Services for Medicaid coverage determination.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: Contains fields for the patient's last name, first name, and middle initial.
- 2. Date of Birth: Fields for the patient's date of birth in MM/DD/YY format.
- 3. CIN #: Field for the Client Identification Number if available.
- 4. Address: Fields for the patient's street address, city, state, and ZIP code.
- 5. Diagnosis: Field for the treating physician to enter the patient's diagnosis.
- 6. Treatment: Field for the treating physician to describe the treatment provided.
- 7. Date(s) of Treatment/Hospital Stay: Fields for the start and end dates of treatment or hospital stay.
- 8. Physician's Certification: Section for the treating physician to certify the emergency medical treatment, including signature, license number, full name, provider/facility name, MMIS ID or NPI, and date.
- 9. Authorization to Release Medical Information: Section for the applicant/recipient or authorized representative to sign, giving permission to release medical information.
What happens if I fail to submit this form?
Failure to submit this form may result in the denial of Medicaid coverage for the emergency medical treatment provided.
- Medicaid Coverage Denial: Without submitting the form, Medicaid will not cover the emergency medical treatment.
- Eligibility Issues: Not submitting the form can lead to difficulties in determining eligibility for emergency medical treatment under Medicaid.
How do I know when to use this form?
- 1. Emergency Treatment: When an emergency medical condition requires immediate attention, this form certifies the treatment provided.
- 2. Medicaid Eligibility: To ensure Medicaid covers the emergency treatment, the form must be completed and submitted.
Frequently Asked Questions
How do I fill out this form?
Complete the sections for patient information, diagnosis, treatment details, and physician certification. Ensure the treating physician signs the form.
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Upload the form and use our built-in signing feature to add required signatures, then save and download the signed document.
Can I share the completed form through PrintFriendly?
Yes, you can share the completed form via email or generate a shareable link using our sharing feature.
Who needs to use this form?
Medicaid patients, treating physicians, hospitals, Medicaid applicants, and social services workers need this form for certifying emergency medical treatment.
What is the purpose of this form?
The form certifies treatment of an emergency medical condition for Medicaid eligible individuals as required by federal law.
How do I know if my treatment qualifies as an emergency medical condition?
Refer to the definition of an emergency medical condition provided on the form and consult with your treating physician.
What information is required on the form?
You need to provide patient information, diagnosis, treatment details, and have the treating physician certify and sign the form.
Where do I submit the completed form?
Submit the form to the local Department of Social Services as instructed.
Can I save and download the edited form on PrintFriendly?
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