If a facility orders medi-car, service car, or ground ambulance transportation of a resident of the facility by an ambulance service provider, the facility must maintain a written record that shows (i) the name of the person who placed the order for that transportation and (ii) the medical reason for that transportation. Additionally, the facility must provide the ambulance service provider with a Physician Certification Statement on a form prescribed by the Department of Healthcare and Family Services in accordance with subsection (g) of § 5-4.2 of the Illinois Public Aid Code. The facility shall provide a copy of the Physician Certification Statement to the ambulance service provider prior to or at the time of transport. The Physician Certification Statement is not required prior to the transport if a delay in transport can be expected to negatively affect the patient outcome; however, the facility shall provide a copy of the Physician Certification Statement to the ambulance service provider at no charge within 10 days after the request. A facility shall, upon request, furnish assistance to the transportation provider in the completion of the form if the Physician Certification Statement is incomplete. The facility must maintain the record for a period of at least 3 years after the date of the order for transportation by ambulance.