\\
Back Home

Completing this form will facilitate processing of the transportation services request. If the patient has Medicare, a Physician Certification Statement (PCS) must be completed and provided to the ambulance crew.

* Required Information

Patient Information

Patient Name *

SSN# * (this is requested on the confirmation call)

Date of Birth / /

Insurance Information

Insurance Company (Primary/Secondary)
Policy #
Group #
Prior Authorization
If Medicaid,
Pre-Authorization #
(PAN)

Transportation Information

Pick up Address or Facility *
Department/Room# *
City, State Zip City State
Zip*
Destination Address or Facility *
City, State Zip City State
Zip*

Level of Service *

 




 

Service

Date of Service * Pick a date
Requested Pick-up time
Appointment Time *
Special Equipment Needed *
MONITOR O2 IV VENT PUMP

Metro Wheel Chair
OTHER
Special Precautions
Admitting Diagnosis *
Reason for Transport *
Sending Physician

Caller Information

Caller's Name & Title *
Call Back Phone Number *
Email (to receive a copy by email)

* Required Information

 

You will receive a call within 15 minutes that your request was received and and expected arrival time will be provided.