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Puerto Rico Medicaid Program OutofState Emergency Service Attestation Form Provider NameProvider NPI #Address Line 1 (Street Name and Number×Address Line 2 (Suite, Room, etc.×CityStateDate of Service
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What is out of state emergency?
Out of state emergency refers to a situation where an individual faces a medical crisis or emergency while traveling or residing outside of their home state.
Who is required to file out of state emergency?
Anyone who experiences a medical emergency while outside of their home state is required to file an out of state emergency report.
How to fill out out of state emergency?
To fill out an out of state emergency report, individuals can contact their home state's emergency services department or healthcare provider for guidance.
What is the purpose of out of state emergency?
The purpose of out of state emergency reporting is to ensure that individuals receive appropriate medical care and assistance while away from their home state.
What information must be reported on out of state emergency?
Information such as the individual's name, location, type of emergency, and contact information must be reported on an out of state emergency form.
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