AUTHORIZATION FOR NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES
Please upload this signed authorization through the My Account Portal or email it to:
admin@transport4us.com
This form serves as authorization for Transport4us LLC to provide and/or dispatch
non-emergency medical transportation services for the authorized patient/member.
By signing this authorization, the undersigned authorizes Transport4us LLC to arrange
transportation to and/or from a doctor's office, medical facility, nursing home, residential facility,
or other authorized medical destination.
A return trip from the doctor's office, medical facility, nursing home, or residential facility may be
provided when necessary. However, the medical facility, patient, resident, or authorized
representative must contact Transport4us LLC to request return transportation.
IMPORTANT TRANSPORTATION POLICY
Under no circumstances will a Transport4us LLC vehicle be required to wait at an Emergency
Room (ER), hospital, or medical facility while the patient is receiving treatment or awaiting
discharge.
If transportation is needed after treatment or discharge, please contact Transport4us LLC at
760-930-1112 to arrange transportation.
TRANSPORTATION REQUEST PROCEDURE
Call Transport4us LLC at 760-930-1112 to request transportation.
Complete and sign this authorization form.
Return the signed form by:
Uploading it through the My Account Portal, or
Emailing it to admin@transport4us.com.
Transportation services will be coordinated according to the applicable authorization and
scheduling requirements.
Transport4us LLC
Phone: 760-930-1112
Email: admin@transport4us.com
By signing below, I acknowledge that I have read and understand the above transportation
authorization and procedures and authorize Transport4us LLC to provide the requested