Healthcare Transportation Partnership Application
Complete all required sections to begin on-boarding with Legacy 1115 Transportation. Our team will review you within 24-48 hours to finalize partnership details. We partner with hospitals, dialysis centers, rehabilitation facilities, and case management teams to provide safe, reliable non-emergency medical transportation.
Organization Information
Organization Name
*
Facility Type
*
Hospital
Dialysis Center
Nursing Facility
Rehabilitation Center
Assisted Living
Other
If Other, please specify Facility Type
Facility Address
*
City / State / ZIP
*
Primary Contact Information
Full Name
*
Title / Position
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best Time to Contact
Transportation Needs
Services Required
*
Ambulatory
Wheelchair
Stretcher
Estimated Weekly Trips
Preferred Service Start Date
-
Month
-
Day
Year
Date
Appointment Types
Dialysis
Medical
Rehab
Discharge
Other Notes
Scheduling & Billing
Service Days
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Pickup Windows
Morning
Afternoon
Evening
Primary Payor Type
Medicaid
Private Pay
Facility Billing
Billing Contact Name
Billing Email
example@example.com
Authorization
Authorized Signature
*
Date
*
-
Month
-
Day
Year
Date
Printed Name
*
Title
*
Submit Partnership Request
Submit Partnership Request
Should be Empty: