Section 1:

Facility / Requestor Information

Facility Name

Contact Person

Title / Role

Phone

Facility Address

Section 2:

Patient / Resident Information

Resident / Patient Name

Date of Birth

Month

Day

Year

Mobility Type (select one)

Special Needs / Instructions

Section 3:

Appointment Details

Appointment Date

Appointment Time

Time

HoursMinutes

Destination Name

Destination Address

Country/Region

Address

City

Zip / Postal code

Purpose of Trip

Return Trip Needed?

Pick-Up Time (for return)

Time

HoursMinutes

Section 4:

Authorization & Billing

Billing Contact

Billing Email

PO Number / Reference (if applicable)

Date

Terms

Focus 1 Health Consulting provides non-emergency medical transportation (NEMT) services for long-term-care residents, assisted-living facilities, and rehabilitation centers.All rides are pre-scheduled and subject to vehicle availability. Requests should be submitted at least 24 hours in advance.