• Health Insurance Transportation Assistance Request Form

    Use this form to request transportation assistance for a health-related appointment or covered medical trip.

  • Member and Contact Information

  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Transportation Request Details

  • Trip Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Desired Pickup Date and Time
     - -
    2 digit month, 2 digit day, 4 digit year
  • Transportation Type*

  • Mobility and Assistance Needs

  • Wheelchair accessible vehicle needed*
  • Mobility aids used
  • Mobility assistance required*
  • Door-to-door assistance needed*
  • Are there stairs at pickup or drop-off?

  • Insurance and Eligibility Information

  • Is this trip for a covered appointment or referral?*
  • Prior approval or authorization already obtained?*

  • Emergency Contact and Communication Preferences

  • Format: (000) 000-0000.
  • Preferred communication methods for appointment reminders or trip updates
  • Should be Empty:
Select theme: