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THIS FORM MUST BE COMPLETED AND SIGNED PRIOR TO TRANSPORT Lifeguard Dispatch 1-888-UNM-PALS 1-888-866-7257 Fax 505 272-2466 STATEMENT OF MEDICAL NECESSITY Milessm Lifeguard Are Emergency Services 2211 Lomas Blvd NE Albuqueque NM 87106 ICD-9 Date of Transport Point of Pick up Zip code MR Flight Patient Name SSN Address City State Zip Patient s diagnosis for air ambulance transport Secondary diagnosis Was the patient s condition critical Yes No Was.

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