Medical Transportation Forms


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

Effective 03/19/2020, all other transports to non-urgent services will be postponed, and other normal routine visits will not be schedule until 04/06/2020 at the earliest. If an appointment cannot be postponed or if a clinician calls to request their patient be present for services, then the transport will be honored.

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. 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. 

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