# The Medi-Cal PCS Form for NEMT: Required Parts, Who Signs It, and How Plans' Forms Differ

Canonical URL: https://nemtguide.com/guides/medi-cal-pcs-form/ · Updated 2026-10-02

The Medi-Cal PCS form, or Physician Certification Statement, is the prescriber's order for a wheelchair van, litter van, ambulance, or air ride. DHCS All Plan Letter 22-008 requires every plan's form to list the member's functional limits, the dates of service up to 12 months, the mode, and a signed certification. The plan approves it, and neither the plan nor its broker may change the mode.

- Every Medi-Cal plan uses its own DHCS-approved PCS form, and each must cover functional limits, dates of service, the mode, and a certification.
- The prescriber picks the mode. The plan, its broker, and your company cannot change it unless the prescriber checked more than one.
- A PCS lasts 12 months at most, and plans count those months differently, from the signature or from the first trip.
- Emergency room to inpatient moves and acute hospital discharges to nursing or psychiatric facilities need no prior authorization.
- Fee-for-service members need an approved TAR with a written prescription instead of a plan's PCS form.

## What the PCS form is and when a trip needs one

Medi-Cal covers a ride by ambulance, litter van, or wheelchair van when the member's medical and physical condition rules out a car, taxi, or bus (22 CCR 51323(a)). That is nonemergency medical transportation, or NEMT. For members in a Medi-Cal health plan, DHCS All Plan Letter 22-008 (May 18, 2022) makes NEMT subject to prior authorization, and the member must have an approved Physician Certification Statement (PCS). As of September 2026, DHCS's list of all plan letters still shows APL 22-008 as the current transportation letter, with no newer letter in its place.

The PCS is the prescriber's order, and it is for NEMT only. DHCS's FAQ on the letter (version 4) says a PCS cannot authorize nonmedical transportation (NMT), such as a car, taxi, or rideshare, and a plan's NMT process cannot require a provider's signature. For enrollment and the plans in each county, see the [California guide](https://nemtguide.com/states/california/). For how other states handle the same kind of form, see [NEMT medical necessity forms](https://nemtguide.com/glossary/medical-necessity-form/).

### When no PCS is needed

- **Hospital moves.** No prior authorization is required for a transfer from an emergency room to an inpatient bed, or from an acute care hospital right after an inpatient stay to a skilled nursing facility, an intermediate care facility, or an inpatient psychiatric setting. L.A. Care's provider page says no PCS is needed for these moves. The plan must provide the acute hospital discharge within 3 hours of the request, or the hospital may arrange an out of network ride that the plan must cover. See [hospital discharge transportation](https://nemtguide.com/guides/hospital-discharge-transportation/).
- **Organ donors.** A living donor in a major organ transplant gets NEMT without a PCS.
- **Urgent trips.** When a PCS could not reasonably come first, a plan may authorize the ride by phone. The member's provider must then send the PCS after the trip for that phone authorization to stand. L.A. Care asks for PCS forms within 24 hours of the NEMT trip being performed.

## The four parts every Medi-Cal PCS must have

Each plan uses its own PCS form, approved by DHCS, and must send the form back to DHCS for approval after any change. APL 22-008 sets four parts that every version must include:

1. **Function limitations justification.** The specific physical and medical limits that keep the member from walking without help or riding in a public or private vehicle.
2. **Dates of service needed.** A start date and an end date, 12 months apart at most.
3. **Mode of transportation needed.** Ambulance, litter van, wheelchair van, or air.
4. **Certification statement.** The provider certifies that medical necessity decided the type of ride.

The provider fills in every field. The plan keeps a copy for every member who uses NEMT, and it must either share the form or tell the broker or the transportation provider the approved mode and dates of service. Plans cannot hand PCS review to their brokers.

### What each mode on the form means

APL 22-008 ties each mode to the member's condition, drawing on 22 CCR 51323 and Medi-Cal's provider manual:

| Mode | Who it is for |
|---|---|
| Ambulance | Transfers needing IV medication, monitoring, or observation; acute facility to acute facility; new oxygen users; oxygen users who need monitoring |
| Litter van | Members who must ride lying down because they cannot sit for the trip, and who need equipment beyond a car or taxi |
| Wheelchair van | Members who cannot sit in a car or taxi for the trip, must ride in a wheelchair or be helped from door to vehicle, or need extra safety equipment |
| Air | Members whose condition, or practical reasons, rule out ground travel, backed by a written order |

The letter names riders who may qualify for a wheelchair van with a signed PCS: members with severe mental confusion, paraplegia, dialysis, or chronic oxygen needs without monitoring. It also requires NEMT for members who cannot reasonably walk, or cannot stand or walk without help, including those who use a walker or crutches. L.A. Care's and Health Net's forms put those members in a wheelchair van, door to door.

Door-to-door help comes with every NEMT ride. When a member lives in a building that does not meet ADA access rules, DHCS's FAQ says the plan must help from outside the building to the vehicle. If the member needs help from the front door inside the building, the plan must arrange a different mode, such as help from the local fire department or EMTs.

### The prescriber's mode is final

Once the treating provider picks the mode, the plan cannot change the authorization or the form, and the plan or its broker must provide that mode. Brokers cannot triage the member's level of service. Neither the plan nor its broker can downgrade a ride from NEMT to NMT, and that includes an ambulatory door-to-door ride. The only exception is a form with more than one mode checked. Then the plan or broker may use the lowest cost one.

Forms differ on that point. L.A. Care's and Health Net's forms ask the prescriber to check one box. IEHP's form asks for every mode that fits the member, so IEHP can use the lowest cost one. Plans must monitor their brokers at least every quarter, and the checks APL 22-008 suggests include whether brokers change levels and whether NEMT providers give door-to-door help. See [level of service](https://nemtguide.com/glossary/level-of-service/).

## Who can sign a Medi-Cal PCS

APL 22-008 lists physicians, dentists, podiatrists, mental health providers, substance use disorder providers, and physician extenders, meaning physician assistants, nurse practitioners, and certified midwives. Medi-Cal's ground transportation manual (page updated August 2020) adds physical, speech, and occupational therapists. It also says a non-physician practitioner working under a physician needs that authority delegated in a standard written agreement.

Most plans print their own list on the form, so check the form before you count on a signature:

- **IEHP:** the member's primary care provider or treating provider. Its form lists no titles.
- **L.A. Care and Health Net:** a physician, nurse practitioner, physician assistant, certified nurse midwife, dentist, mental health professional, or substance use disorder provider.
- **CalOptima Health:** the same titles plus physical, speech, and occupational therapists and podiatrists.
- **Anthem Blue Cross:** the member's physician or physician extender, including therapists, or a discharge planner employed or supervised by the hospital, facility, or physician's office.
- **Partnership HealthPlan:** its policy (last reviewed January 14, 2026) also allows licensed midwives, optometrists, and chiropractors. The signature line on its January 2026 form names licensed midwives but not optometrists or chiropractors, and it takes a personal signature only, with no proxy and no stamp.

Your company is never on any of these lists. The certification belongs to the prescriber, and the provider fills in every field.

## How long a PCS lasts, plan by plan

A PCS covers 12 months at most. For recurring visits such as dialysis, wound care, or chemotherapy, DHCS's FAQ says the treating provider can sign once for the whole series. The plan then authorizes rides for the length of the appointments, up to 12 months. If the prescriber later leaves the plan's network, the plan keeps providing the rides the PCS authorized until a new treating provider reviews them.

Plans count those months differently and take the form in different places, as these five plans' forms show.

| Plan and form | Where the form goes | How long it lasts |
|---|---|---|
| [L.A. Care](https://nemtguide.com/health-plans/la-care-health-plan/), form LA6957 (August 2025) | Utilization Review Transportation Unit, fax 213-438-2201 | Up to one year from the provider's signature |
| [IEHP](https://nemtguide.com/brokers/iehp/), form approved by DHCS December 23, 2024 | IEHP's Provider Portal, or fax 909-912-1049 | 12 months from the transportation start date, or from the signature if left blank |
| [Health Net](https://nemtguide.com/health-plans/health-net-medi-cal/), form 25-183 (February 2025) | Care Ride Unit, fax 833-701-0051 | 60, 90, 180, or 365 days, with 365 for chronic conditions only |
| [Anthem Blue Cross](https://nemtguide.com/health-plans/anthem-blue-cross-medi-cal/), form CABC-CD-014831-22 (January 2023) | Modivcare Utilization Review, fax 877-457-3352 | Up to 12 months |
| [CalOptima Health](https://nemtguide.com/health-plans/caloptima-health/), 2024 version | Fax 714-338-3153, or 714-571-2424 if urgent | Six or 12 months |

Put each rider's end date on your calendar when the trip comes in, and remind the facility a few weeks before it lapses. Once the dates on the PCS pass, the plan needs a new form before it can authorize more NEMT rides. See [NEMT standing orders](https://nemtguide.com/guides/nemt-standing-orders/) and [dialysis transportation](https://nemtguide.com/guides/dialysis-transportation/).

## Fee-for-service Medi-Cal: a prescription and a TAR

Members who are not in a health plan use fee-for-service Medi-Cal, and the paperwork changes. Rule 22 CCR 51323(b)(2) requires a physician's, dentist's, or podiatrist's prescription and prior authorization for all nonemergency medical transportation. Medi-Cal's ground transportation manual (pages updated August 2020) turns that into a Treatment Authorization Request, or TAR, for every NEMT trip. The TAR goes to the TAR Processing Center with a legible prescription, or for facility residents, an order sheet signed by the physician.

The prescription must state:

- the purpose of the trip,
- how often the member needs visits, or the dates of the rides, and
- the medical or physical condition that makes ordinary transportation inadvisable.

For ongoing rides it must also show the chronic nature of the condition and include a treatment plan from the physician or therapist. A diagnosis alone, such as multiple sclerosis or stroke, does not meet the rule. Modifiers on the TAR and the claim must match for the claim to pay.

There is one exception. A ride from an acute care hospital to a nursing facility, level A or B, needs no TAR, prescription, or clinician signature. For urgent trips, 22 CCR 51323(b)(2)(A) lets the transportation provider ask for authorization by phone, valid only once a written request confirms it.

Some plans use both. Partnership HealthPlan requires a TAR and its own PCS for NEMT services that carry a TAR requirement. For an urgent ride it authorized by phone, its policy has the Medi-Cal certified NEMT provider send the TAR once a valid PCS is in hand. See [Partnership HealthPlan](https://nemtguide.com/brokers/partnership-healthplan/).

## What your company keeps on file

The plan holds the PCS. What your company needs is proof of what was approved and what you drove:

1. **The approved mode and dates.** Plans must pass them to the broker or to you. Partnership will fax or securely email a copy of the PCS if you need one.
2. **A trip record that names the driver.** Plans must require their brokers to identify the provider and driver for every trip by date, time, pickup and drop-off place, and member name. Your logs supply those answers.
3. **Proof of door-to-door help.** It is one of the items plans may check in their quarterly monitoring.
4. **Records kept 10 years.** Welfare and Institutions Code 14124.1 has Medi-Cal providers keep a record of each service for 10 years from the end of the plan contract period, the end of any audit, or the date of service, whichever is later. See [NEMT record retention](https://nemtguide.com/guides/nemt-record-retention/).

## Why NEMT trips stall, and what to do

A trip often stalls on the form itself, for one of these reasons:

- **A blank field.** L.A. Care and Health Net mark required sections with a star and want them all done before the form is sent. CalOptima warns that incomplete or inaccurate forms may cause delays or denials.
- **A diagnosis with no limits.** CalOptima's form says a diagnosis alone is not medical necessity and asks for the member's functional limits.
- **The wrong signer.** The title is not on the plan's list, or at Partnership, the form was signed by proxy or with a stamp.
- **Expired dates.** A rider whose PCS lapsed needs a new one before the next NEMT ride.
- **A mode that no longer fits.** L.A. Care, Health Net, and their vendors cannot edit a form once it is sent, so a different mode needs a new form from the provider.

When a trip reaches you with the wrong mode or an expired PCS:

1. **Drive only the approved level.** The mode on the PCS is the mode you drive and bill.
2. **Tell the broker or plan right away,** so the member does not miss care while the paperwork is fixed.
3. **Ask the facility to send a new PCS** to the plan's fax or portal from the table above.
4. **Never fill in or sign the form for the prescriber.** Hand the clinic the plan's blank form, and let the provider complete it.

## Frequently asked questions

### Does every Medi-Cal wheelchair van ride need a PCS form?

In managed care, nearly every one does. APL 22-008 requires an approved PCS before a plan authorizes NEMT, which covers wheelchair van, litter van, ambulance, and air rides. Emergency room to inpatient transfers and acute hospital discharges to a nursing or psychiatric facility need no prior authorization, and living organ donors need no PCS. Fee-for-service members need a TAR with a prescription instead.

### Can my NEMT company fill out or sign the PCS for a rider?

No. The member's treating provider signs the certification, and APL 22-008 requires the provider to fill in every field. Most plans' forms list the titles that may sign, such as physicians, nurse practitioners, physician assistants, dentists, and mental health providers. Your job is to give the facility the plan's form and fax number and keep the approved mode and dates with your trip records.

### How long is a Medi-Cal PCS form good for?

Twelve months at most, and plans count it differently. L.A. Care's form lasts up to one year from the provider's signature, IEHP's lasts 12 months from the transportation start date, and Health Net's offers 60, 90, 180, or 365 days, with 365 for chronic conditions only. A recurring series such as dialysis can run on one form for up to 12 months.

### Can the broker or health plan change the ride type on a PCS?

No. Once the treating provider picks the mode, APL 22-008 bars the plan and its broker from changing it or downgrading the member from NEMT to nonmedical transportation. The one exception is a form with more than one mode checked, where the lowest cost mode may be used. A different mode needs a new PCS from the provider.

### Do car, taxi, or rideshare rides need a PCS?

No. Those are nonmedical transportation (NMT), and DHCS's FAQ on APL 22-008 says the PCS is for NEMT only and cannot authorize NMT. A plan's NMT process cannot require a provider's signature. A member who asks for gas mileage for a private car must attest that other ways to get to care were tried.

### Does fee-for-service Medi-Cal use the PCS form?

Not the plan forms. Fee-for-service NEMT needs an approved Treatment Authorization Request sent with a legible prescription that states the purpose of the trip, how often or on which dates, and the condition that rules out ordinary travel. Ongoing rides also need a treatment plan, and a diagnosis alone is not enough. A move from an acute care hospital to a nursing facility, level A or B, is the only exception.

## Official resources

- [DHCS: All Plan Letter 22-008 on NEMT and NMT](https://www.dhcs.ca.gov/file/apl22-008-pdf/)
- [Medi-Cal Provider Manual: Medical Transportation, Ground](https://mcweb.apps.prd.cammis.medi-cal.ca.gov/file/manual?fn=mctrangnd.pdf)
- [L.A. Care: PCS form LA6957](https://www.lacare.org/sites/default/files/la6957_pcs_form_202508.pdf)
- [IEHP: NEMT PCS form](https://www.providerservices.iehp.org/content/dam/provider-services-rd/en/documents/providers/provider-resources/forms/umcm-forms/2025/20250107%20-%20NEMT%20Physicians%20Certification%20Statement%20Form_%20DHCS%20Approved.pdf)
- [Health Net: Medi-Cal PCS form 25-183](https://providerlibrary.healthnetcalifornia.com/content/dam/centene/healthnet/pdfs/providerlibrary/5000_Medi-Cal_PCS_Form.pdf)
- [Anthem Blue Cross: Medi-Cal NEMT PCS form](https://www.modivcare.com/wp-content/uploads/2022/10/CA-ANTHEM-NEMT-PCS-Form-FINALv4.pdf)
- [CalOptima Health: NEMT referral request and PCS form](https://www.modivcare.com/wp-content/uploads/2022/10/2024-08_CalOptimaHealth-NEMT_AuthForm.pdf)