Texas Standardized Instruction Sheet
Section 1: Add insurance name, fax number and date of request
Section 2: Non-urgent and initial request
Section 3: Patient information (Note: Insurance ID number is required)
Section 4: Facility and contact person information with signature
Section 5: Start date and end date for all lines (Should be date of transport)

Units for each procedure code are required: Round trips will require 2 units
BLS A0428
ALS A0426
SCT A0434
Mileage A0425 X ______ Units (# of miles)
ALS Disposable A04398
BLS Disposable A0382
Oxygen A0422 (if needed)

Diagnosis and ICD code required
Section 6: Reason why the ambulance is required and destination of
transport.
After faxing the request with supporting clinical documentation to the
Insurance company, forward all documentation to Acadian Ambulance at:
(337)-291-2271 or ATAC@Acadian.com. Be sure to include the Fax Confirmation receipt.