Transportation Services Request Form (Faxed)

Transportation Services Request Form
Notice of 5-7 business days is required.
Name*

First NameLast Name
Alliance ID*
Date of Birth*

MonthDayYear
If traveling alone please have a parent/gaurdian fill out a Non-Emergency Medical Transportation Minor Consent Form and include that in this fax.
Pick Up Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member’s Phone*
Please enter a valid phone number.
Member’s Height*
Member’s Weight*
Stairs at Residence/Facility?*

YesNo
Number of stairs
Provider/Facility Making Request*
Name of Requesting Physician
(Required for gurney transportation)
Request Completed By*
Fax # (if confirmation is requested)
Please enter a valid fax number.
Appointment Information
Appointment Provider/Facility*
Appointment Physician
(Required for gurney transportation)
Appointment Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician/Facility Phone*
Appointment Date/Time*

MonthDayYear
Hour Minutes (HH:MM) MinutesAM/PM Option
Type of Appointment*
Estimated Length of Appointment (hours/minutes)*
Round Trip?*

YesNo
Attendant?*

YesNo
Name of Attendant
Mobility?*

WheelchairGurneyAmbulatory
DX for Gurney Transport
Does the member require oxygen?

YesNo
Litters of oxygen needed
Does the member have a trach tube?

YesNo
What type of suctioning?

ShallowDeep
Other specific conditions/equipment?
Important: Please include PCS form with gurney transport request if we do not already have one on file.
Important: Please contact the Alliance ambulatory service provider Call the Car at 833-244-1678
If you have any questions, please contact the Alliance Transportation department at 831-430-5640 or toll free at 800-700-3874 ext. 5640.

In the event that a member needs to reschedule their appointment, please contact the Alliance to make the appropriate changes. Thank you!

Please preview, print and fax this completed form to 831-430-5850
Should be Empty:

Transportation Services Request Form

Notice of 5-7 business days is required.

Appointment Information

Please preview, print and fax this completed form to 831-430-5850