Palmer's Transportation

TRANSPORTATION REQUEST FORM

In order to appropriately serve your request, please complete all form fields below including physician signature and date of signature.

Facility Name*

First

Date*

Address

Street Address Address Line 2 City State ZIP Code

PATIENT INFORMATION

Person’s last name:*

First Middle Last

Medical I.D.

The current Nursing Facility outside Dr. Appointment request form is:*

Attached, since this person currently resides in a Nursing Facility.
Not applicable, since this patient resides at home.

Dates of Service:*

To:

Return Service:*

To:

Appointment Start Time*

: HH

MM

Appointment End Time*

: HH

MM

Wait time if required*

Day(s) of the week transported to the above appointment:*

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Patient mobilizes via:*

Wheelchair
Walker
Stretcher
Cane
Other (describe)

Comment:

Transportation purpose/justification for visit(s)

Functional limitations, (specific physical or mental), that preclude the person’s ability to be without assistance or to be transported by Non-Medical Transportation: (Please include on Nursing Facility outside Dr. Appointment request form.)

PAYMENT INFORMATION

Person responsible for bill: [Responsible party]

Nursing Facility: Nursing Facility: Co-payment

Payment Details Billing Address:

Nursing Facility: Nursing Facility: Co-payment

COMFIRMATION

I Agree*

The above information is true to the best of my knowledge. I authorize payment to Palmer’s Non-Medical Transportation. I also authorize Nursing Facility or insurance company to release any information required to process my request.

Nursing Facility Rep/Patient/Family Member’s signature*