Ambulance Signature Form

​The signature form is a form that the patient or authorized patient representative signs before transport. 

Section I

Patient signature - only to be signed by the patient if they are capable of making informed decisions about their care and are able to sign for themselves. This section may also be signed by the parent/guardian of a minor if they are present. 

Section II

This section may be signed by a legal representative of the patient if they are mentally or physically incapable of signing for themselves. 

Section III

This section may be signed by the patient's medical provider in the event that the patient is not capable for signing for themselves AND they do not have an authorized representative to sign for them. You must state the circumstances that make it impractical for the patient to sign the form. In addition to a signature from the transferring provider, this will also be signed by the crew member who is transporting the patient. 

Click on the button below to print out an Ambulance Signature Form.


Physician Certification Statement (PCS)

The PCS form is required for all interfacility transports. ​Before transferring care to the 9 Line Med transport crew, please fill out this statement and ensure that it is signed by the transferring physician, RN, or other qualified provider listed in section III of the form. Please make sure that the provider's name is legible and their title/credentials follow their name. Click on the button below to print out a PCS form.

If you are a sending facility interested in requesting a transport, please print out each of the following forms and follow the instructions below when completing the forms. Hand the completed forms to the 9 Line Med crew upon their arrival.

Toll Free: 866-205-8330

24/7 Ambulance Dispatch, Serving Nebraska and Kansas

Forms for Sending Facilities