What every Medi-Cal PCS form must show
DHCS’s All Plan Letter 22-008 lets each plan design its own form but sets four things every one must carry:
- The member’s function limitations: the specific physical and medical limitations that rule out walking without help or riding in a public or private vehicle.
- The dates of service needed: a start and an end date, for at most 12 months.
- The mode of transportation needed: ambulance, litter van, wheelchair van or air.
- A certification statement: the provider certifies that medical necessity decided the type of transport.
Once the treating provider has chosen the mode, neither the plan nor its broker can change it; a form that ticks more than one mode may be filled with the lowest-cost one. The term is explained in full under PCS form.
PCS forms by plan
| Plan | Form | Who signs | Where it goes | How long it lasts |
|---|---|---|---|---|
| L.A. Care | LA6957, Non-Emergency Medical Transportation Physician Certification Statement (revised August 2025). Open the form | A physician, nurse practitioner, physician assistant, certified nurse midwife, dentist, mental health professional or substance use disorder provider (the form’s own list) | Faxed to L.A. Care’s Utilization Review Transportation Unit (the number is on the form), not to Call the Car | Up to one year from the provider’s signature; the dates of service cover at most 12 months |
| IEHP | IEHP’s own DHCS-approved PCS form. We found no public download of it; IEHP’s provider notices send NEMT requests through its secure Provider Portal | The member’s provider, before the transportation request | IEHP (NEMT requests go through IEHP’s secure Provider Portal) | For all NEMT requests for 12 months from the transportation start date |
| Health Net | Form 25-183, Non-Emergency Medical Transportation Physician Certification Statement (February 2025). Open the form | A physician, nurse practitioner, physician assistant, certified nurse midwife, dentist, mental health professional or substance use disorder provider (the form’s own list) | Faxed to Health Net’s Care Ride Unit (the number is on the form) for prior authorization, before ModivCare is contacted | Up to one year from the provider’s signature; the form offers 60, 90, 180 or 365 days, the last for chronic conditions only |
| Anthem Blue Cross | Non-Emergent Medical Transportation Physician Certification Statement Form (CABC-CD-082056-25, April 2025). Open the form | The member’s care provider or a physician extender (physician assistant, nurse practitioner, certified nurse midwife, physical, speech or occupational therapist, mental health or substance use disorder provider), or a discharge planner employed or supervised by the hospital, facility or provider’s office | To ModivCare, by e-mail or fax, attention Utilization Review (both are on the form); the provider manual asks for it within two business days of receiving it | Authorization of up to 12 months, paid only while the member is eligible on the date of service |
| Partnership HealthPlan | Partnership’s own Provider Certification Statement (PCS) for NEMT; policy MPTP2501 accepts no other plan’s form. Open the form | MD, DO, DPM, PA, NP, DDS, CNM, LM, physical, speech or occupational therapists, and mental health or substance use disorder providers; personal signature only, no proxy and no stamps | Partnership, which reviews it before the ride is arranged | Dates of service of at most 12 months, dependent on member eligibility |
| SFHP | Authorization Request for Non-Emergency Transportation (NEMT) and Physician Certification Statement (PCS), form 000855C (October 2024). Open the form | A physician, dentist, podiatrist or mental health provider, or a physician extender; SFHP says nurses and social workers may not prescribe NEMT | SFHP’s transportation coordinator by fax or e-mail (both on the form); typed only, handwritten forms aren’t accepted | One date, or ongoing for up to 12 months; renewed every year |
| HPSJ | Physician Certification Form – Request for Transportation (DHCS approved 2022, revised October 23, 2023; posted on HPSJ’s forms page May 7, 2024). Open the form | A physician, dentist, podiatrist, mental health provider, substance use disorder provider, or a physician extender employed or supervised by the hospital, facility or office treating the patient | Faxed to the plan (the number is on the form); HPSJ reviews it itself and tells the transportation vendor about the approval | A number of trips, or 30, 60 or 90 days, 6 months or 12 months; at most 12 months under policy UM55 |
CenCal Health, Molina Healthcare and CalOptima Health have their own forms too; what we could confirm about them is on NEMT in California.
When a PCS form isn’t needed
- NMT. L.A. Care, Health Net and San Francisco Health Plan all say NMT requests don’t need the form; the member attests there is no other way to get to the appointment.
- Certain transfers. No prior authorization is needed from an emergency room to an inpatient setting, or from an acute care hospital, right after an inpatient stay, to a skilled nursing, intermediate care or inpatient psychiatric facility.
- Urgent care, for now. When there was no time to send a form, the plan can approve the ride by phone and the provider sends the PCS afterwards. L.A. Care asks for it within 24 hours of the trip; San Francisco Health Plan takes retro requests within 30 calendar days of the date of service.
Fee-for-service Medi-Cal: a TAR instead
Trips billed straight to fee-for-service Medi-Cal don’t use a plan’s PCS form; they need an approved Medi-Cal TAR with a signed prescription. One plan asks for both: Partnership HealthPlan wants a TAR from the NEMT provider as well as its own PCS form for services with a TAR requirement.
What a transportation company keeps from the form
- The mode. The van that shows up must match it.
- The dates, and which date they count from: the provider’s signature for L.A. Care and Health Net, the transportation start date for IEHP.
- The authorization number the plan or broker gives, which goes on the trip sheet and the claim.
- Whether the form is in yet, for plans that accept it after the trip.
A standing order that runs past an expired form is the costly mistake: the rides are driven and the legs can’t be billed. NEMT billing software that holds a leg until its authorization is on file catches it before the claim does.
Questions
Which PCS form should a doctor use?
The member's own plan's form. Each Medi-Cal plan uses its own DHCS-approved version, and some accept no other: Partnership HealthPlan accepts only its own form.
Where do PCS forms go: the plan or the broker?
It depends on the plan. L.A. Care, Health Net, San Francisco Health Plan and Health Plan of San Joaquin take the form themselves; Anthem Blue Cross's form goes to ModivCare, attention Utilization Review. The plan keeps the review either way.
How long does a Medi-Cal PCS form last?
At most 12 months of dates of service. L.A. Care and Health Net count up to one year from the provider's signature; IEHP counts 12 months from the transportation start date.
Sources
Checked on . Rules change: check the current version with the payer before you bill.
- DHCS All Plan Letter 22-008: Non-Emergency Medical and Non-Medical Transportation Services and Related Travel Expenses (May 2022)
- L.A. Care: NEMT Physician Certification Statement, form LA6957 (revised August 2025)
- L.A. Care: Transportation (providers, utilization management)
- Health Net Medi-Cal: NEMT Physician Certification Statement, form 25-183 (February 2025)
- Anthem Blue Cross Medi-Cal: Non-Emergent Medical Transportation Physician Certification Statement form
- Partnership HealthPlan of California: Provider Certification Statement (PCS) for NEMT
- San Francisco Health Plan: Authorization Request for NEMT and Physician Certification Statement (000855C, October 2024)
- SFHP: Transportation services (providers)
- Health Plan of San Joaquin: Physician Certification Form – Request for Transportation (revised October 23, 2023; posted May 7, 2024)
- IEHP: Transportation (members)