Non-Medical Transportation

Non-Emergency Medical Transportation (NEMT) Request Form

Helping Hands Superior Care LLC / 5006 Trouble Creek RD Suite 228, New Port Richey, FL 34652 / 866-521-7606
SECTION 1: CLIENT INFORMATION
Client Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Home Address Pickup Location
SECTION 2: APPOINTMENT DETAILS
Date of Appointment

MonthDayYear
Date
Time of Appointment
Destination Name eg ClinicHospital
Destination Address
Reason for Visit
SECTION 3: TRANSPORTATION NEEDS
Does the client require a wheelchairaccessible vehicle YesNo
Will a caregiver or aide be accompanying the client (Yes/No)
Return trip needed (Yes/No)
Any special instructions or accommodations
Requested By Name
Relationship to Client
Signature

Clear
Should be Empty:

SECTION 2: APPOINTMENT DETAILS