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: _____________________________________

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Care Facility Use Only:

Facility Name_____________________________________________________ Phone Contact # _______________

Coordinator ______________________________________________________ Fax Contact # ____________________________

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