Follow the steps to successfully complete the online form

1. Press the ‘Get Form’ button to access the IEHP Transportation Request Form (Hospital) and open it in the online editor.
2. Begin by entering the IEHP Member ID, member name, height, and weight. Note that height and weight are required if transportation is via wheelchair or gurney.
3. Indicate if trach to ventilator, trach to oxygen, and oxygen are needed by selecting 'YES' or 'NO' for each pertinent field. Provide the liter flow and FIO2 if applicable.
4. Complete the COVID-19 test data section. While this is not required, fill in the test administered, test results, and corresponding dates if available.
5. In the 'Transportation From' section, fill in the facility and treating physician's name, room number, address, city, zip code, contact person, and their phone number.
6. Proceed to the 'Transportation To' section, providing all relevant details about the destination facility, room number, receiving physician/caregiver, address, city, zip code, contact person, and their phone number.
7. Select the mode of transportation under 'Transportation By' and indicate preferences such as wheelchair type or the need for a gurney. Specify if stair support is needed and how many stairs are involved.
8. Fill in the names of both the sending physician and receiving physician/caregiver.
9. Finally, save your changes, and choose to download, print, or share the completed form as needed.

Complete your IEHP Transportation Request Form (Hospital) online today for efficient processing.