Healthcare Transport Authorization

Healthcare Transport Authorization

Patient Information

Date of Birth:     Gender:

Primary Phone:     Secondary Phone/Cell:

Relationship:     Phone:

Insurance / Billing

Policy Number:     Group Number:

Subscriber Date of Birth:

Requested Transport Details

Requested Date of Transport:     Appointment Time / Window:

Estimated One-Way Travel Time:

Ambulatory (walks independently)     Wheelchair assistance     Stretcher

Requires medical attendant during transport     Requires oxygen during transport     Bariatric support required

Medical History / Clinical Information

Authorization and Consent

I, the undersigned patient or authorized representative, authorize and request the designated transport provider and its agents to arrange and provide non-emergency medical transport for the patient identified above to the facility or address listed. I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge.

I understand that transport involves risks including but not limited to falls, delays, aggravation of existing conditions, and unforeseen medical events. I consent to reasonable and necessary assistance and routine medical care during transport, including basic life support measures if an emergency arises, and authorize transport personnel to obtain emergency medical treatment if deemed necessary to stabilize my condition until I can be transferred to an appropriate care provider or emergency facility.

I authorize release of medical and personal health information to the transport provider, receiving facility, and billing agents as necessary to arrange transport, provide care during transport, and process claims. This authorization includes pertinent medical history, medication lists, allergies, and diagnosis related to the transport. I understand I may revoke this authorization in writing except to the extent actions have been taken in reliance on this authorization.

I agree to be responsible for charges not covered by insurance, including applicable co-payments, deductibles, and no-show or cancellation fees as set by the transport provider. I understand billing disputes must be addressed directly with the billing office and do not negate the obligation to pay for services rendered.

I hereby release and hold harmless the transport provider and its employees from liability for loss or damage arising from transportation and related non-emergency care, except for acts of gross negligence or willful misconduct. This release is subject to applicable law and does not waive rights that cannot be waived by law.

Acknowledgments

By signing below I acknowledge that I have read and understand this authorization. I understand that I may withdraw this authorization at any time by providing written notice to the transport provider, provided that withdrawal will not affect any action taken in reliance on this authorization prior to receipt of such notice.

If signing on behalf of the patient, I certify that I am authorized to do so as a legal guardian, healthcare proxy, or other lawful representative and I will provide supporting documentation upon request.

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