Schedule Transport

 
IMPORTANT! Before completing the secure form, please make sure you have the following information from your insurance company: Group Number, ID Number, Auth Number.
* Required Field
CUSTOMER INFORMATION
Are you a current subscriber?* Yes     No
Please call 610-398-0239 Ext. 525 to find out how you can receive discounts by becoming a subscriber.
Name (Last, First, Middle)*
Social Security Number* --
Sex*
Date of Birth (mm/dd/yyyy)*
Age*
Weight (lbs)*
   
INSURANCE INFORMATION
Guarantor Name*
Guarantor Telephone Number*
Guarantor Email Address*
Guarantor Street Address*
Guarantor City*
Guarantor State*
Guarantor Zip*
Primary Insurance Company Name*
Check this box if you do not have insurance. Payment will be required at time of confirmation.
Group Number*
ID Number*
Auth Number Auth Number
Secondary Insurance Company Name
Group Number
ID Number
Auth Number
Is this a Skilled Nursing Facility (SNF)?*
Do you have Medicare Part A?*
Medicare Number
Do you have Medicaid or Medical Assistance?*
Medicaid/Medical Assistance Number
   
PRIMARY CARE PHYSICIAN
First Name*
Last Name*
Telephone Number*
   
TRANSPORTATION INFORMATION
If transporting from address is a facility, please list name of facility
If doctors office, please include doctor's name and suite number
Transporting From Street Address*
Transporting From Street Address 2
Transporting From City*
Transporting From State*
Transporting From Zip*
Transporting To Street Address*
Transporting To Street Address 2
Transporting To City*
Transporting To State*
Transporting To Zip*
Receiving Facility Telephone*
Type of Call* Ambulette Ambulette
Basic Life Support (BLS) Basic Life Support (BLS)
Advanced Life Support (ALS) Advanced Life Support (ALS)
Wheelchair Wheelchair
Medi-Car Medi-Car
If requesting a wheelchair transport, do you have your own chair?*
Starting Transport Date (mm/dd/yyyy)*
Is this recurring?*
Repeats*
Repeat Every* days
Repeat on* S    M    T    W    T    F    S
Repeat by* day of the month    day of the week
Ends* Never
After occurrences
On
Pickup Time (h:mm am/pm)*
Appointment Time (h:mm am/pm)*
Return Time (h:mm am/pm)*
Medical Reason for Transport*
Do you require oxygen during transport?*
Number of steps at pick up address*
Can you go up and down the steps on your own?*
   
READ THOROUGHLY BEFORE SIGNING

BY TYPING NAME BELOW I certify that all data provided on this application is true and accurate.
Signature*
Date*
   
Enter the code you see above* (Case Sensitive)