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
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Telephone Number
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?
*
Yes, I am covered
Member ID #
Plan Name
Medicaid
Medicare
Managed Medicaid
Other Insurance
Emergency Contact Name
Relationship to Client
Address
Telephone
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
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