The L.A. Care PCS form — the Physician Certification Statement — is what a treating provider signs to authorize Non-Emergency Medical Transportation for a member whose medical condition makes travel by ordinary car, bus, or taxi unsafe. Without one on file, L.A. Care will not schedule a wheelchair van, gurney van, ambulance, or air transport. Download the current version from the L.A. Care provider portal, complete every asterisked field, and fax the signed form to the Utilization Review Transportation Unit at 213-438-2201.
Who Can Sign
The form lists the provider types authorized to certify medical necessity. Physicians, nurse practitioners, physician assistants, certified nurse midwives, dentists, mental health professionals, and substance use disorder providers can all sign. The signer must be the provider responsible for the member’s care and must apply medical necessity criteria to choose the specific transport mode requested.
Nothing on a submitted PCS can be altered after the fact. Not by L.A. Care staff, not by the transportation vendor, not by the provider’s office. If a detail changes or an error surfaces, the provider completes a fresh form and submits it again.
Filling Out the Form
Every field marked with an asterisk is mandatory. Miss one and the form comes back, the ride doesn’t get scheduled, and the member waits. The form has six main sections.
Patient Information
Enter the member’s first name, last name, date of birth, and L.A. Care ID number (also called the CIN, printed on the Medi-Cal Benefits Identification Card). Include the phone number and full address. If a caregiver will coordinate rides or travel with the member, add the caregiver’s name and phone number.
Requesting Provider Information
Print the provider’s full name and title, office phone, fax number, and National Provider Identifier — the ten-digit number assigned to every covered healthcare provider under HIPAA.
Mode of Transportation
This is the section where requests most often go wrong. Medi-Cal requires the lowest-cost transport mode that safely meets the member’s needs, and L.A. Care’s utilization review team will flag a request that doesn’t match the documented limitations.
- Wheelchair van, for members who cannot walk without assistance, use a wheelchair or walker, or need door-to-door help getting in and out of a vehicle. A bariatric wheelchair request also needs the member’s height and weight.
- Litter or gurney van, for members who cannot sit upright for the length of the trip and must travel lying down. Bariatric gurney requests also need height and weight.
- Ambulance, at Basic Life Support, Advanced Life Support, or Specialty Care Transport level, depending on the medical monitoring needed during the ride.
- Air transport, which requires separate prior authorization from L.A. Care before the PCS is submitted.
Duration of Service
Enter a start date and an end date. The maximum authorization period is 12 months from the date of the provider’s signature. For a chronic condition like ongoing dialysis, using the full 12-month window avoids monthly resubmissions. For post-surgical recovery or a temporary injury, match the end date to the expected recovery timeline. When the authorization expires, the provider reassesses and submits a new PCS if NEMT is still warranted.
Physical and Medical Limitations
Check every box on the checklist that applies to the member:
- Behavioral issues
- Blind
- Dementia
- Extensive medical support required (ventilator, IV, and the like)
- Hemiplegic
- Hemodialysis
- High fall risk (specify the reason)
- Oxygen required
- Paraplegic
- Poor exercise tolerance
- Cannot reasonably ambulate — unable to stand or walk without assistance, needing door-to-door help even without a wheelchair, such as a walker or crutch user
- Other, with a write-in for any functional or physical limitation not listed
The member’s medical condition has to be the direct cause of the transportation barrier. Lack of a car, distance to the appointment, or general inconvenience does not qualify.
Diagnosis Codes
Enter up to four ICD-10 codes for the conditions that create the mobility impairment. The codes should directly support the transport mode and the limitations you checked. A mismatch between the diagnosis and the requested service level is one of the fastest ways to trigger a denial.
Submitting the Form
Fax the signed form to the Utilization Review Transportation Unit at 213-438-2201. L.A. Care’s provider guidance directs that PCS forms be submitted within 24 hours of the NEMT trip so that activity is documented accurately and rides aren’t delayed. For questions about a pending authorization or to speak with a utilization management reviewer, call L.A. Care’s UM department at 1-877-431-2273 (collect calls accepted).
Members scheduling rides for routine appointments should call L.A. Care Member Services at 1-888-839-9909 (TTY: 711) and select the transportation prompt at least 48 hours before the appointment, Monday through Friday. L.A. Care’s current transportation vendor, Call the Car, Inc., handles scheduling and dispatch once the PCS authorization is in place.
What Happens After You Send It
The utilization management team reviews the clinical information against Medi-Cal’s NEMT criteria. If the request meets the criteria, the system generates an authorization number tied to the member’s profile, and Call the Car uses that number to schedule and bill for rides. Members and providers receive notification through mail or the secure provider portal, confirming the authorized dates and transport type.
When a provider marks the request urgent — meaning the standard review timeline could seriously endanger the member’s life, health, or ability to function — L.A. Care must decide within 72 hours of receiving the request. Standard requests follow the plan’s regular processing timeline.
If the Request Is Denied
A denial triggers a Notice of Action letter explaining the reason. The most common causes are incomplete forms (missing ICD-10 codes, unsigned certification, blank mandatory fields), a mismatch between the documented limitations and the requested transport level, and insufficient clinical detail showing why standard transportation is medically unsafe.
If the form was simply incomplete, correct the deficiency and resubmit a new PCS. If the denial rests on a clinical judgment the provider disagrees with, the member has 60 days from the date of the Notice of Action to file an appeal with L.A. Care. Standard appeals must be resolved within 30 days. Expedited appeals, for situations where delay could harm the member’s health, must be resolved within 72 hours.
If L.A. Care upholds the denial on appeal, the member can request a State Fair Hearing through the California Department of Social Services within 90 days of the notice date. Hearing requests can be filed online at cdss.ca.gov/hearing-requests, by fax to 833-281-0905, or by phone at 1-800-743-8525 (TTY: 1-800-952-8349). To keep receiving transportation services while the hearing is pending, the member must request the hearing within 10 days of the appeal denial notice or before the date the notice says service will end, whichever is later.
Don’t Use the PCS for Standard Rides
The PCS form applies only to NEMT: wheelchair vans, gurney vans, ambulances, and air transport for members whose medical condition prevents safe use of ordinary vehicles. Members who can physically ride in a car, taxi, or bus but lack a way to get to a Medi-Cal appointment qualify for Non-Medical Transportation instead, which has no PCS requirement and is arranged directly through L.A. Care Member Services. Filing a PCS for someone who actually qualifies for NMT leads to unnecessary denials.
Keeping the Authorization Current
The authorization ends on the end date written on the form, and no PCS can run longer than 12 months from the provider’s signature. For members with ongoing conditions such as dialysis, spinal cord injuries, or progressive neurological disease, calendar the expiration and reassess before it lapses. A gap between an expired PCS and a new one cuts off NEMT rides until a fresh form is processed. If a member changes treating providers mid-authorization, L.A. Care must continue the currently authorized services until the existing PCS expires, and the new provider then submits a replacement going forward.