Transport Request

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Transport Request

To request medical transportation, fill out this form.

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.

Oxygen

Cardiac Monitoring

IV Medication

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

Submit

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This form was created inside of Union City, Ohio Fire & Rescue.