PWW Free Forms Library


Welcome to the PWW Free Forms Library! 
We are pleased to provide this resource free of charge to the EMS community.

 

Check back often for updates to these documents and to make sure you have the most current ones.  Please read the important information below, then help yourself to the free forms on this page.





Forms and signature issues are covered in detailed sessions at the abc3 conferences. 
Registration for our Fall 2013 Conference is open!
  Click HERE to go directly to the abc3 page for more information or to register!



Terms of Use

Medicare and Billing-Related Forms
: Any individual or entity who downloads or uses these documents or any modified version of any of these documents in any way is referred to as the "User."  The documents made available for download on this site are sample forms and policies only, designed to assist ambulance services in complying with applicable requirements. These documents are not legal advice, and no attorney-client relationship is formed by their use. Unless otherwise noted, these documents are not official forms of any governmental agency and may not reflect requirements of state law where you live. User bears all responsibility for compliance with all applicable laws and regulations, and the User agrees that neither Page, Wolfberg & Wirth, LLC nor the individual designers of these documents are not responsible for their use, non-use or modification by any User. Do not use any of these documents or any modifications of them if you do not agree to the terms and conditions of this license. These documents may be modified by the User to meet the User’s needs, though we bear no responsibility for any modifications. These documents are licensed only for use by individual ambulance services, and may not be sold or distributed by any other individual or entity.  All Any other use or distribution of these documents requires our express written permission.  Please also note that we expect to periodically update these documents for various reasons, and we cannot be responsible to distribute new or updated forms to users.  In addition, we do not guarantee that these documents will be updated to reflect new laws, regulations or other applicable authority.  All documents are Copyrighted by Page, Wolfberg & Wirth, LLC, and any use, reproduction or distribution that is not in accordance with these Terms of Use is strictly prohibited unless permitted in writing by Page, Wolfberg & Wirth, LLC.


Medicare and Billing-Related Forms

Sample Ambulance Signature Form - Version 2.1 - New!

Word

 PDF

Instructions

Physician Certification Statement - Version - 1.6

Word 

PDF

Instructions

Sample Signature Attestation Statements - Version 1.1

Word 

PDF

 

Sample Signature Logs - Version 1.2

Word 

 PDF 

 

Sample Advance Beneficiary Notice of Noncoverage*

Word 

PDF 

 

*Note: this is an official government form, only limited modification is permissible, and PWW makes no copyright claim over government works.




Patient Refusal Documentation

Sample Patient Informed Decision Making Form - Version 1.4 

Word

PDF

Policy





IMPORTANT:  By clicking any of these links and/or downloading any of these documents, you agree to the Terms of Use spelled out below.  DO NOT download any of these documents if you do not agree to these terms. If you download any documents, you agree to these Terms of Use.