Transportation Request

Pickup Location

Drop Off Location

Patient & Transportation Information

Special Instructions/Covid Results:

Which of these apply?

Which of these apply?

Payor Information

This area is the person or facility that is paying for the medical transport.

Authorization has been given to Servant’s Heart for the transportation of this patient. The risks and benefits of the transportation have been explained to the patient by the facility, as well as the risks and benefits for the forgoing transport. The above information is deemed true and accurate and I verify that the patient is ready for transportation. The receiving facility has been contacted, has the available space and is qualified for the treatment of the patient; they have also agreed to accept the patient in transport. Servant’s Heart, LLC will not be expected to perform any medical procedures during transport. Cancellation of transport must phone and fax, 30 minutes prior to assigned pick-up time in order to receive credit. Failure to confirm cancellation will result in an “Unloaded” charge, equal to a one way fee.