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Standing Order Trip - Request for Transportation Services 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting the order status: New Order, Revision, or Cancellation. If revising or canceling, enter the original confirmation number.
- Fill in the patient’s name, Health First Colorado ID number, date of birth, and today’s date.
- Provide the agency or hospital name along with a contact person and their phone number.
- Enter the drop-off address details including street address, city, state, zip code, location name, suite number, and phone number.
- Repeat step 5 for the pick-up address.
- Specify the time of appointment and return time if applicable. Also indicate start and end dates along with days of travel.
- Select the trip purpose from options like Dialysis or Chemo. If other, describe it in the provided space.
- Complete the agreement section by entering your name and signature to certify accuracy of information provided.
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Thank you for your continued support. Please feel free to contact Parking and Transportation Services at 315.443.4652 with any questions regarding departmentRead more
Standing orders or specific controlled substances orders for individual patients to be administered at specified times shall not be valid after seven days