Request for Transportation provided by A-Transportation

Fax 843-347-4520 Request From: (print facility name)

____________________________________________________________________________

Contact Name: _______________________________________________________________       

Phone: _____________________ Ext#:___________ Fax: ___________________________

Patient Information (Please print clearly)

Date of Order_________/_________/__________ Date of Service_________/_________/__________

Pick-up Time ____:____ Appointment Time: _____:_____ or Back Time: ______:______

Will call: ________ Round Trip: _____ One-way:______ # Steps_______ # of companions: _______

M___ F___ DOB: _______/_______/_______

Phone: ___________________ Patient’s Name:__________________________________________

From: ____________________________________________________________________________

Destination: _______________________________________________________________________

Phone: _____________________ Doctor/Medical: _______________________________________

Must be completed by authorized person only _____ Direct billing

(Required signature to guarantee payment must be completed below)

Name: ______________________________________________________________

Title ________________________________________________________________

Billing address: _______________________________________________________

Phone: (______) ____________________ ext __________ Fax__________________

Claim /Case Number: ___________________________________________________

I hereby authorized the above transportation.

Signature: ___________________________________________________Date: ________________