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Request for local or non local medical transportation assistance 2026
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How to use or fill out request for local or non local medical transportation assistance
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- Click ‘Get Form’ to open it in the editor.
- Begin with Part 1 - Patient Information. Fill in the applicant's and patient's last names, first names, and telephone numbers accurately.
- Move to Part 2 - Medical Appointment Information. Provide details about your appointment including date, time, location, and the name of the specialist or hospital. Ensure you include contact numbers for both the specialist and referring medical practitioner.
- Indicate if a medical escort is required and provide validation type if applicable. This may include a physician's note.
- In Part 3 - Travel Information, specify your departure and return dates, travel location, and whether you can contribute to transportation costs. Include any accommodation needs or special arrangements necessary.
- Finally, complete Part 4 - Declaration by signing and dating the form to confirm all information is true.
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Related links
The Non-Emergency Medical Transportation (NEMT) program provides eligible members transportation needed to get to their medical appointments.Read more
Mar 23, 2012 A list of Medicaid-enrolled transportation providers, by service and/or borough, is available upon request by contacting LogistiCare via emailRead more
These transportation services include wheelchair vans, taxis, stretcher cars, bus passes and tickets, secured transportation containing an occupant protectionRead more