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.
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 and NOT for providers. A new form must be completed for every transport.