PATIENT TRIP BOOKING
Medicaid - Medical or Behavioral Health
Please Select Insurance plan
*
AHCCCS INDIAN HEALTH PLAN
MERCY CARE
Please Select appropriate health plan
TRIP DATE
*
/
Month
/
Day
Year
Date
REQUESTED DRIVER IF ANY
First Name
Last Name
PATIENT NAME
*
First Name
Last Name
PATIENT PHONE NUMBER
*
-
Area Code
Phone Number
AHCCCS NUMBER
*
LEAVE BLANK IF UNKNOW
DATE OF BIRTH
*
/
Month
/
Day
Year
Date
REASON FOR APPOINTMENT
*
AS DETAILED AS POSSIBLE
TIME OF APPOINTMENT
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
30
Minutes
AM
PM
AM/PM Option
REQUEST RETURN TIME
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
30
Minutes
AM
PM
AM/PM Option
WILL CALL - SELECT IF NOT SURE ABOUT RETURN TIME
PICK UP LOCATION
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DROP OFF LOCATION
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ambulatory
Wheelchair
Stretcher
ESCORTS
NAME OF ESCORT *** ONE ESCORT ONLY
COMMENTS
UPLOAD ANY RELATED DOCUMENTS
Browse Files
Cancel
of
Please Rate Our Services
1
2
3
4
5
SUMBIT
Submit
Should be Empty: