(a) In this Section:
         "Ambulance service provider" means a Vehicle Service
    
Provider as defined in the Emergency Medical Services (EMS) Systems Act who provides non-emergency transportation services by ambulance.
        "Patient" means a person who is transported by an
    
ambulance service provider.
    (b) If a hospital arranges for transportation of a patient of the hospital by ambulance, the hospital must provide the ambulance service provider, prior to transport, a Physician Certification Statement formatted and completed in compliance with federal regulations or an equivalent form developed by the hospital. The Physician Certification Statement or equivalent form is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome.
     (c) If a hospital is unable to provide a Physician Certification Statement or equivalent form, then the hospital shall provide to the patient a written notice and a verbal explanation of the written notice, which notice must meet all of the following requirements:
         (1) The following caption must appear at the
    
beginning of the notice in at least 14-point type: Notice to Patient Regarding Non-Emergency Ambulance Services.
        (2) The notice must contain each of the following
    
statements in at least 14-point type:
            (A) The purpose of this notice is to help you
        
make an informed choice about whether you want to be transported by ambulance because your medical condition does not meet medical necessity for transportation by an ambulance.
            (B) Your insurance may not cover the charges for
        
ambulance transportation.
            (C) You may be responsible for the cost of
        
ambulance transportation.
            (D) The estimated cost of ambulance
        
transportation is $(amount).
        (3) The notice must be signed by the patient or by
    
the patient's authorized representative. A copy shall be given to the patient and the hospital shall retain a copy.
    (d) The notice set forth in subsection (c) of this Section shall not be required if a delay in transport can be expected to negatively affect the patient outcome.
     (e) If a patient is physically or mentally unable to sign the notice described in subsection (c) of this Section and no authorized representative of the patient is available to sign the notice on the patient's behalf, the hospital must be able to provide documentation of the patient's inability to sign the notice and the unavailability of an authorized representative. In any case described in this subsection (e), the hospital shall be considered to have met the requirements of subsection (c) of this Section.