Medical Transportation Forms

Information

All dialysis, radiation, chemotherapy, physical therapy, substance use disorder counseling, or other recurring transportation services will continue to be provided as scheduled.

** Upcoming Holiday Closures: Our office will be closed on Monday, February 20, 2023, in observance of President's Day, reopening on Tuesday, February 21, 2023. Per the State of Maryland, no rides will be scheduled during these closures. Therefore, it is the client’s responsibility to find their own method of transportation during these holiday closures.


Provider Certification Form

The Provider Certification Form (PCF) is required for every client and must be updated annually or as medical conditions change. As of July 1, 2018, there is only one certification form for all mobility – ambulatory, wheelchair, and stretcher.

Distant Transport Form

The Distant Transport Form is required for every out-of-area referral. The frequency of forms may vary. Contact our office for more information.

Transfer & Discharge Form

 For transfers or discharges from a facility, please use the Transfer & Discharge form. A new form must be completed for every transport. Note: transfers from nursing homes can only be completed if the patient is being transferred to a higher level of care. 

Special Programs Transportation Request Form

 The Special Programs Transportation Request Form is required for any scheduled transportation rides by a program within the Wicomico County Health Department. A new form must be completed for every transport.




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