Travel Assistance Request Form

STEP 1 of 9

Here's what you'll need to complete this request

These items are required to submit your application.

Appointment verification

Letter, portal screenshot, or email confirmation clearly showing the patient's name

Proof of income

Tax return or SSI/Disability letter and 3 months of bank statements

Patient Details

Full legal name, date of birth, address, phone, email

Caregiver Information

For all medically-necessary caregiver(s) who will travel with the patient

Physician & Facility Information

Healthcare provider details for your appointment

Important Information

We only collect information necessary to arrange your medical transportation.

This form takes approximately 10-15 minutes to complete.