Transport Estimate

Step 2 of 3 · Passenger
Passenger Name

First NameLast Name
Passenger Estimated Weight (lbs)
How will this ride be paid?
Which health plan or medical group?
As shown on the member card. We do not work with Medi-Cal or Medicare at this time.
Authorization number
If you have it. The medical group or doctor’s office can provide it.
We don’t work with this health plan. We can still take this ride as private pay. Dispatch will confirm the cost with you before anything is booked.
Private pay acknowledgment

Step 3 of 3 · Contact
Primary Contact Information

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Text updates
By checking this box, you agree to receive text messages from Golden State Medical Transport about your transport request, such as confirmations, reminders and arrival updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not required to book. See our Privacy Policy and Terms.
Primary Contact responsible for Billing?
Please provide contact person who is responsible for Billing

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
pick up estimate
One Way Transport Estimate $
Round-Trip transport Estimate $
Should be Empty:

Request transport