Reminder – Physician Certification Statement (PCS) Form – Update

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Date: October 30, 2018
To: Health Plan of San Joaquin (HPSJ) Practitioners and Providers
From: HPSJ [Medical Management Department]
Subject: Reminder – Physician Certification Statement (PCS) Form
Business: Medi-Cal


As we continue to seek ways to streamline processes, Health Plan of San Joaquin has simplified prior authorization requirements for transportation for your busy office.

Attached please find the UPDATED PCS form. Please note the options for NEMT versus NMT mode of transportation. HPSJ requires a completed Physician Certification Statement (PCS) form to approve transportation for Non-Emergency Medical Transportation (NEMT).

Download form

If your patient needs medical transportation to an appointment, HPSJ requires supporting documentation (see section of PCS form, after you “select the type of transportation patient requires”). Ambulation with a walker or cane will not be sufficient. If your patient can safely attend appointments using non medical transportation, please indicate NMT on form and return. No additional documentation will be needed. Additionally, all authorizations that are approved for NEMT will be valid for the duration of the PCS form, up to six months.

If a member needs additional transportation during the time the PCS is valid, you will not need an additional authorization unless:

  • Transportation provider is different than the original request
  • CPT codes are different
  • Change in patient condition

If needed, HPSJ will work with our providers (PCPs and Specialists) to obtain PCS forms on behalf of Transportation agencies.

Our HPSJ network providers are important partners in delivering care to our members. We hope this change will be helpful for you and your practice. If you have questions, please contact our Customer Service Department at 209-942-6320.

Posted on October 31st, 2018 and last modified on September 9th, 2022.