Request for Non-Emergency Medical Transportation (NEMT)

Are you receiving any help or support with completing this form?

Yes

No

If yes, please provide the name of the person assisting you with this form and their relationship to you/the client.

Client's First Name

Client's Last Name

Email

Contact Phone

When is the best time to reach you?

Morning (8 AM – 12 PM)

Afternoon (12 PM – 4 PM)

Evening (4 PM – 8 PM)

Anytime

Date of Birth

Month

Day

Year

How will you cover the cost of your trip?

Medicaid Insurance

Private Pay

Pick Up Address

Drop-off (Appointment) Address:

Date and Time of Appointment:

Month

Day

Year

Time

HoursMinutes

Preferred Pickup Time (if different from appointment time):

Time

HoursMinutes

Type of Appointment

Primary Care, Dentist, etc.

Specialist, Dialysis, Therapy, etc.

Shopping, Errands, etc.

Personal, Family Event, etc.

Do you require a wheelchair-accessible vehicle?

Yes

No

Do you need assistance getting to or from the vehicle?

Yes

No

Return Trip Needed?

Yes

No

If yes, what time should the return pickup be scheduled?

Time

HoursMinutes

What is the name and number of your emergency contact person?

Is there anything else you'd like for us to know (gate code, parking instructions, etc.)?

How did you hear about us? (Select all that apply)

By checking this box, you confirm that you are 18 years of age or older and give us permission to contact you/the client.