Schedule Stretcher Transport

"*" indicates required fields

Patient's Name*
Medicare A/100 Day Stay*

Please Provide Face Sheet For Patient

MM slash DD slash YYYY

Any patient needing vent could be charged additional fees if using AmeriKare equipment

Pick Up Address*

Drop Off Address*

(*Please note if this transport is a wait and return additional charges may apply* the first 30 minutes are included in the facility rate)
****Over this will be charged $60.00 per 15 minutes increments****

Facility Payment Agreement

Schedule A Transport