Medical Certificate of Transportation Services Beyond 25 Miles

To be valid, the Attending Physician, Physician’s Assistant, Nurse Practitioner, Therapist or other licensed healthcare professional must fully complete and sign this certification form.
Agreement and signature: I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil or both. I certify under penalty of perjury, that I have obtained the information on the form from the patient or their representative, and the information provided is accurate to the best of my knowledge.