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* Female Male 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* Pennsylvania No State or Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Pacific Armed Forces Europe Armed Forces Americas 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 Secondary Insurance Company Name Group Number ID Number Auth Number Is this a Skilled Nursing Facility (SNF)?* No Yes Do you have Medicare Part A?* No Yes Medicare Number Do you have Medicaid or Medical Assistance?* No Yes 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* Pennsylvania No State or Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Pacific Armed Forces Europe Armed Forces Americas Transporting From Zip* Transporting To Street Address* Transporting To Street Address 2 Transporting To City* Transporting To State* Pennsylvania No State or Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Pacific Armed Forces Europe Armed Forces Americas Transporting To Zip* Receiving Facility Telephone* Type of Call* Ambulette Basic Life Support (BLS) Advanced Life Support (ALS) Wheelchair Medi-Car If requesting a wheelchair transport, do you have your own chair?* No Yes Starting Transport Date (mm/dd/yyyy)* Is this recurring?* No Yes Repeats* Daily Every weekday (Monday to Friday) Every Monday, Wednesday, and Friday Every Tuesday and Thursday Weekly Monthly Yearly Repeat Every* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 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?* No Yes Number of steps at pick up address* Can you go up and down the steps on your own?* No Yes     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)