Motiv Patient Intake & Transportation Consent Forms

Motiv Client Intake & Transportation Consent Forms
Who is completing this form
If you are completing this form on behalf of patient, please provide your name & contact information below,
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Mobility & Transport Needs
Other
Special instructions or notes
Payment / Billing Type
Medicaid Info

only if you selected Medicaid above
Medicaid ID number
Clinic / Provider name
Safety Awareness
Type a question
Agreement & Signature
Liability Waiver

I acknowledge that MOTIV provides non-emergency medical transportation only. I understand that:
- MOTIV staff are not medical providers and do not provide medical care.
- I am responsible for my personal belongings.
- I agree to hold MOTIV harmless from liability for any injury or incident that may occur during transport, except in cases of gross negligence.
HIPAA Authorization
I authorize MOTIV to use and disclose my protected health information (PHI) as necessary to coordinate and provide transportation services. This may include sharing information with healthcare providers, facilities, and caregivers strictly for purposes related to my transportation and care.

I understand that:
- My information will be handled in accordance with HIPAA regulations.
- I may revoke this authorization at any time in writing.
- This authorization is valid for ongoing services unless revoked.
Policies & Procedures Acknowledgment
- Clients must be ready at the scheduled pickup time.
- Cancellations must be made at least 2 hours prior to pickup.
  A $35 fee will be charged for no-shows or late cancellations (less than 2 hours notice).
- Repeated no-shows may result in service suspension.
Communication Consent: By providing your phone number, you consent to receive SMS/text messages from MOTIV regarding transportation bookings, reminders, updates, and service-related notifications. Messages and data rates may apply.
By signing below, you acknowledge and agree to all policies.
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

Motiv Client Intake & Transportation Consent Forms

Patient Information

Emergency Contact

Mobility & Transport Needs

Medicaid Info

Safety Awareness

Agreement & Signature