Transport Request
To request medical transportation, fill out this form.
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Your Name *
Your Phone Number *
Transport From *
Select the most appropriate answer.
Departure Address *
Type the address where the patient will be picked up
Transport To *
Select the most appropriate answer.
Destination Address *
Type the address where the patient will be brought to.
What is the transport date? *
Use mm/dd/yyyy format.
What is the appointment time? *
Use 24 Hour format. For conversion of times after noon, add 12 hours. I.e. a 3:00 PM appointment would be 3+12=15:00
Patient's Name & Room Number *
Type room number if applicable. I.e. if the patient is being transported from a facility or hospital.
Requested Level of Care *
What is the level of certification required for this transport.
Orders for Medications or Procedures
Not required for all patients.
Special Instructions
Any additional information. i.e. "The patient is non-ambulatory due to broken left leg.
Patient Weight *
How much does the patient weigh?
Method of Payment *
Indiana Medicaid requires prior authorization by Indiana Medicaid with approximately a two week lead time. Medicare MUST include Part B
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This form was created inside of Union City, Ohio Fire & Rescue.