Get Southeastrans Nursing Home Transportation Request Form 2021-2025

This guide provides clear instructions on completing the Southeastrans Nursing Home Transportation Request Form online. Follow these steps to ensure a smooth and efficient submission process.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the nursing home name in the designated field, followed by the contact person's name, which can be a nurse or social worker.
3. Input the nursing home address, including the street address, city, state, zip code, and contact phone number. Additionally, provide the fax number for any required documentation.
4. Fill in the appointment details, including the appointment date, time, and day of the week. Indicate whether the appointment is in the AM or PM.
5. Enter the member or patient’s name, Medicaid number (12 digits), and date of birth in the respective sections.
6. Specify the appointment type and the destination facility's name, including the facility's street address, city, county, state, and zip code.
7. Complete the contact information for the destination facility, including the destination phone number and any specific details such as the floor or room number.
8. Select the mode of transportation needed, indicating if an escort is required. Provide details for the escort, including their name and relationship to the patient.
9. Answer any questions related to travel, including wheelchair specifications, patient requirements for mask wearing and sanitization, as well as any relevant health inquiries related to COVID-19.
10. Before submitting, review all entries for accuracy. Save changes, download a copy, and print or share the completed form as needed.

Start filling out the Southeastrans Nursing Home Transportation Request Form online to ensure timely transportation arrangements.