Healthcare Travel Authorization Form

HEALTHCARE TRAVEL AUTHORIZATION FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other

Insurance Information

Travel Authorization Details

Requested Travel Date:

Ambulance (emergency)    Non-emergency stretcher    Wheelchair-accessible van

Commercial airline    Private vehicle    Other:

Escort Required: Yes    If yes, Escort Name:

Medical Considerations for Transport

Mobility aids: Cane   Walker   Wheelchair   Stretcher

Oxygen required during transport: Yes    If yes, oxygen flow rate / details:

Anticoagulant or blood-thinning medication: Yes    Seizure disorder history: Yes

Authorizations, Risks, and Financial Responsibility

I authorize the release of pertinent medical information necessary for arranging and providing transport to the identified transport provider. Transport provider may receive clinical information that is necessary to ensure safe transfer and care during transit. Transport provider:

I acknowledge that medical transport involves risks including, but not limited to, delays, exposure to motion, changes in condition, or complications related to transfer. I have been provided the opportunity to ask questions and understand the benefits and risks of the requested transport. I accept these risks: Yes

I authorize billing to the health insurance identified above for services rendered during transport. I understand that I am financially responsible for charges not covered by insurance, including any non-covered services, missed cancellations, or third-party fees. I accept financial responsibility: Yes

This authorization permits disclosure of protected health information to the transport provider for purposes of arranging and providing transport and is limited to information necessary for those purposes. I understand this authorization may be revoked in writing at any time except to the extent that action has already been taken in reliance on it.

Authorization Expiration Date: (If left blank, authorization remains in effect for one year from signature where permitted by law.)

Patient Acknowledgment and Consent

By signing below I certify that I have read and understand the information above, that the facts I have provided are accurate to the best of my knowledge, and that I voluntarily authorize the transport described herein. I understand I may withdraw this authorization at any time in writing, but withdrawal will not affect actions taken in reliance on this document prior to receipt of the revocation.

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