Get Southeastrans Nursing Home Transportation Request Form

Completing the Southeastrans Nursing Home Transportation Request Form online is an essential step to ensure that transportation services meet the needs of users. This guide provides a clear, step-by-step instruction to help you successfully fill out the form with all necessary details.

Follow the steps to complete your request form effectively.

1. Press the ‘Get Form’ button to acquire the document and open it in your chosen editor.
2. Begin filling out the first section with the nursing home’s name, contact person (nurse or social worker), and their telephone number. Ensure the telephone number includes the area code.
3. Continue with the nursing home’s street address, state, county, and zip code. Double-check each field for accuracy.
4. Select the appointment date, including the month, day, and year. Indicate the time of the appointment and the return pickup time, circling the corresponding day of the week.
5. In the next section, provide the member’s name, Medicaid number, and date of birth. Please pay careful attention to the member’s information.
6. Specify the destination facility’s name, street address, city, and zip code. It’s also essential to include the destination phone number.
7. Indicate the mode of transportation required for the member, selecting between options such as ambulatory, wheelchair, or electric wheelchair. Specify if an escort is required.
8. If applicable, provide details on the member’s weight and wheelchair width if the wheelchair is wider than 18 inches. For BLS or ALS, include the patient’s weight.
9. Fill in the escort's relationship to the patient and their name, ensuring that contact numbers are completed for follow-up.
10. Confirm whether the patient requires an attendant and specify the preferred transportation provider, if any.
11. Review the completed form for accuracy and clarity. Once everything is properly filled out, you can save changes, download, print, or share the form.

Complete your Southeastrans Nursing Home Transportation Request Form online today to ensure timely and necessary transportation services.