MEDICAL APPOINTMENT SCHEDULE
RIDE REQUEST APPLICATION (PAGE 1)
Customer Name: ______________________________________Phone: _______________Personal ID: _______________________
Address: ___________________________________________________________________Date of Birth: _____________________
Mobility: Uses Wheelchair Can Transfer from W/C Ambulatory
Supplied by Customer Requires Attendant Uses Walker
Supplied by Transporter Oxygen Uses Cane
Over 28x40 in. / Over 600 lbs Additional Equipment
Mode Request: (We approve the lowest cost mode based on your mobility)
Fuel Voucher - Driver Must Have Current License, Insurance, and Vehicle Registration on File at SMS
Bus Pass Pass Type: Adult Youth Reduced Fare Para Transit/VIP
Ride (Taxi, Wheelchair Van, Etc.)
Other Comments:
(For out of area requests or specialist appointments, please include referring doctor’s name and phone.)
(THIS SECTION IS FOR ONE-TIME APPOINTMENTS:
List all medical appointments you have scheduled for the month. The medical service must be covered by your medical program.
|Appt |Appt |Reason for Appointment |Doctor or Clinic Name |Address/Suite/City |Phone |One |Rnd Trip|
|Date |Time |(Illness, Injury, Dental Care, Etc.) | | | |Way | |
| |(Am/Pm) | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
RIDE REQUEST APPLICATION – (PAGE 2) Customer Name: ______________________________________
(THIS SECTION IS FOR YOUR ROUTINE WEEKLY APPTS, FOR A GIVEN MONTH, THAT ARE WITH THE SAME PROVIDER:
Check the days of the week and show appt times.
Your transportation will be set up for the same day/time each week, for the ENTIRE month unless you state otherwise in the comments section above.
|Month |Days of |Appt Time |Reason for Appointment |Doctor or Clinic Name |Phone |One |Rnd Trip |
| |Week |(Am/Pm) |(Illness, Injury, Dental Care, Etc.) |Address/Suite/City | |Way | |
| |TU | | | | | | |
| |W | | | | | | |
| |TH | | | | | | |
| |F | | | | | | |
| |S | | | | | | |
| |SU | | | | | | |
| | | | | | | | |
| |TU | | | | | | |
| |W | | | | | | |
| |TH | | | | | | |
| |F | | | | | | |
| |S | | | | | | |
| |SU | | | | | | |
(I understand appointments are subject to verification prior to transportation provision.
_________________________________________________________ _________________________________________________________
(Signature) (Print Name)
___________________________________________ ____________________________________________
(Relation to Customer) (Phone Number)
SMS requires at least two full business days before your medical appointment to review and process requests.
OFFICE USE ONLY:
Appointment Date(s) ______/______ ______/______ ______/______
Pick-up Time(s) ______:______AM PM ______:______AM PM ______:______AM PM
Comments ______________________________________________________________________________
Confirmation Date ______/______/____________ By: _____________________________________
-----------------------
Care Facility Use Only:
Facility Name_____________________________________________________ Phone Contact # _______________
Coordinator ______________________________________________________ Fax Contact # ____________________________
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