Travel Assistance Request Form

STEP 1 of 9

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

These items are required to dddd 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

Gas Card Assistance Update: Unfortunately, due to limited funding, Mercy Medical Angels is unable to provide gas card assistance for the remainder of 2026, with the exception of certain qualifying Air Force members and Veterans. We sincerely apologize for the inconvenience and appreciate your understanding.

We only collect information necessary to arrange your medical transportation.

This form takes approximately 10-15 minutes to complete.