Psychiatrists Licensed by the Board of Medical Examiners



Transportation Services Information Form

1.0 CONTRACTOR Identification – Provide Administrative Office Information

|CONTRACTOR Name: | |Administrative Address:| |

|Phone Number | |City, State, | |

|Cell Phone Number: | |Zip Code: | |

|Fax Number: | | | |

|E-Mail Address: | |Contact Person: | |

| | |Phone Number: | |

|Name & Title of Authorized | | | |

|Signatory: | | | |

2.0 CONTRACTOR BUSINESS LICENSE – Main license issued to operate in the State of Arizona in accordance with applicable state and local laws (i.e., taxi, shuttle, wheelchair transports, wheelchair vans, handicapped accessible vehicles, etc.)

|Licensing Authority:       |

|License Number:      |License to Operate in County(s):       |

|Expiration Date:      |

3.0 CONTRACTOR SERVICES

Check the types of vehicles you will be providing services with (you can check more than one):

| Transportation Vehicle (ambulatory) | Transportation Van (ambulatory) |

| Provide up to 5 passenger services | Provide up to15 passenger services |

| Handicap Accessible | Handicap Accessible |

| Provide car and/or booster seats | Provide car and/or booster seats |

| Handicap accessible vehicles | Wheelchair /Handicap accessible Vans |

|(non-ambulatory) |(non- ambulatory) |

| Provide up to 5 passenger services | Provide up to15 passenger services |

| Handicap Accessible | Handicap Accessible |

| Provide car and/or booster seats | Provide car and/or booster seats |

3.1 Indicate any specialty experience

| Blindness | General Mental Health | Speech Disorders |

| Conduct Disorders | Hearing Impaired | Substance Abuse Dependence |

| Developmental Disorders | Mental Retardation | Suicide |

| Disruptive Behaviors | Parent/Child Problems | other, specify: |

| Family Problems | Seriously Mentally Illness | |

3.3 Service Areas (Geographic Areas): Check each Region which the service(s) will be offered. If providing services throughout the State, check all Regions (see Exhibit F for listing of regions).

|Region |Entire Region (Yes or No) |If answered "no", what parts of the Region are excluded. |

| Central | | |

| Pima | | |

| Northern | | |

| Southeastern | | |

| Southwestern | | |

4.0 STAFFING/FACILITY LOCATION – the following pertains to the location(s) where services will be delivered:

|Contractor Name: |      |

|Physical Address: |      |

|City, State, Zip Code: |      |

|Telephone No: |      |Contact Name:      |E-mail:      |

| |

|Days/Hours of Operation (Office Only): | Monday – Friday | Evening | Saturday Sunday |

| |Hrs.:_____ |Hrs.:______ |Hrs.: _____ Hrs.:___ |

|List all holidays that the Facility will not be open:| |

| |

|Spanish Speaking: | Yes | No |Other Non-English Language (Specify): |

4.1 VEHICLES AVAILABLE

Please provide a list of vehicles your company will use for this contract, including the number of vehicles, vehicle make, model, year, and what services it provides.

|VAN # |Plate # |Vehicle Description |Type of Service |Seating Capacity |

|Example: 800 |CES524 |2008 Ford E150 |Wheelchair service |1 Regular and 2 Wheelchairs |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

5.0 SUB-CONTRACTOR IDENTIFICATION (fill this page out for each sub-contractor)

|SUB-CONTRACTOR Name: |      |Administrative Address:| |

|Phone Number: | |City, State, | |

|Fax Number: | |Zip Code: | |

|E-Mail Address: | |Contact Person: | |

| | |Phone Number: | |

|Name & Title of Authorized | | | |

|Signatory: | | | |

5.1 SUB-CONTRACTOR BUSINESS LICENSE

Main license issued to operate in the State of Arizona in accordance with applicable state and local laws (i.e., taxi, shuttle, wheelchair transports, wheelchair vans, handicapped accessible vehicles, etc.)

|Licensing Authority:       |

|License Number:      |License to Operate in County(s):       |

|Expiration Date:      |

5.2 SUBCONTRACTOR STAFFING/FACILITY LOCATION - the following pertains to the location(s) where services will be delivered:

|Sub-Contractor Name: |      |

|Physical Address: |      |

|City, State, Zip Code: |      |

|Telephone No: |      |Contact Person:      |E-mail:      |

| |

|Days/Hours (Office Only): | Monday – Friday | Evening | Saturday Sunday |

| |Hrs: |Hrs: |Hrs: Hrs: |

|List all holidays that the Facility will | |

|not be open: | |

| |

|Spanish Speaking: | Yes | No |Other Non-English Language (Specify): |

|Region(S) |Entire Region (Yes or No) |If answered "no", what parts of the Region are excluded. |

| Central | | |

| Pima | | |

| Northern | | |

| Southeastern | | |

| Southwestern | | |

5.3 SUBCONTRACTOR SERVICES

Check the types of vehicles you will be providing services with (you can check more than one):

| Transportation Vehicle (ambulatory) | Transportation Van (ambulatory) |

| Provide up to 5 passenger services | Provide up to15 passenger services |

| Handicap Accessible | Handicap Accessible |

| Provide car and/or booster seats | Provide car and/or booster seats |

| Handicap accessible vehicles | Wheelchair /Handicap accessible Vans |

|(non-ambulatory) |(non- ambulatory) |

| Provide up to 5 passenger services | Provide up to15 passenger services |

| Handicap Accessible | Handicap Accessible |

| Provide car and/or booster seats | Provide car and/or booster seats |

5.4 VEHICLES AVAILABLE

Please provide a list of vehicles the subcontractor will use for this contract, including the number of vehicles, vehicle make, model, year, and what services it provides.

|VAN # |Plate # |Vehicle Description |Type of Service |Seating Capacity |

|Example: 800 |CES524 |2008 Ford E150 |Wheelchair service |1 Regular and 2 Wheelchairs |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download