VTC CLIENT RECERTIFICATION FORM
Please help us update our records by completing this form. Questions? Call Volunteer Transportation Center at 315-788-0422.
Client Name
Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Telephone Number
Format: (000) 000-0000.
Do you need assistance getting in or out of your home or doctor's office?
Yes
No
Do you use:
wheelchair
cane
walker
rolling walker
Veteran Status
*
Please Select
Veteran
Spouse of a Veteran
Not Applicable
What do you have for insurance coverage?
*
Rows
Yes, I am covered
Member ID #
Plan Name
Medicaid
Medicare
Managed Medicaid
Other Insurance
Emergency Contact Name
Relationship to Client
Address
Telephone
Format: (000) 000-0000.
Sometimes we get things wrong. If the client is no longer in need of our services, please check this box to be removed from our database. (i.e.: moved out of state, now living in a nursing home, passed away)
please remove the client
Signature
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Submit
Should be Empty: