1. (a) Each ambulance provider shall maintain supporting records in accordance with He-W 520 and He-W 521.

2. (b) Each ambulance provider shall maintain documentation in their records to fully support each claim billed for services, including:

   1. (1) For emergency transportation, documentation of the nature of the recipient’s emergency medical condition; and
   2. (2) For all ambulance transportation, documentation that justifies the level of service, whether ALS or BLS, claimed.

3. (c) For each trip billed in (b) above, the ambulance provider shall maintain a run sheet or patient care report that includes at a minimum the following information, which is legibly written:

   1. (1) Recipient name and medicaid identification number;
   2. (2) Date of service;
   3. (3) Origin and destination;
   4. (4) Recipient vital signs;
   5. (5) Recipient signs and symptoms upon arrival at the point of pick-up;
   6. (6) Recipient status en-route;
   7. (7) Services provided;
   8. (8) The name of the person who provided the service or care in the ambulance, including signature and credentials; and
   9. (9) The response code that indicates the mode of response for the ambulance making the trip.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05 New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13 (from He-W 572.06); ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24