Schedule Wheelchair Transport

"*" indicates required fields

Patient's Name*

First Last

Gender*

Weight*

Primary Insurance*

Insurance Number*

Secondary Insurance*

Insurance Number*

Social Security Number*

Medicare A/100 Day Stay*

Yes

Please Provide Face Sheet For Patient

Private Pay Contact Information

Transport Date*

Appointment Time*

Reason for Transport*

Whose Wheelchair*

Wheelchair

Patient's Wheelchair

We cannot accommodate wheelchairs over 30” wide; most powerwheelchairs are not suitable for transport.

Special Needs*

Pick Up Location*

Room #*

Address*

Street Address City State ZIP Code

Pick up location additional notes*

Drop Off Location*

Room #

Address*

Street Address City State ZIP Code

Drop Off location additional notes*

Dr's Name*

Phone Number*

Requestor Name*

Requestor Phone Number*

Requestor’s Email*

(*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

Administrator/Authorized personnel: (Type name)*

Administrator/Authorized personnel**

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Quick Links

Our Services

Get In Touch

2212 WILSON RD, COLUMBUS OHIO 43228

6145928223

info@primecareems.com

Quick Links

Get In Touch

Phone Number

(614)-344-4004

Fax Number

(614)-344-4007

Email

info@primecareems.com

1st Location

665 East Dublin Granville Rd COLUMBUS OHIO 43229

2nd Location

4852 Delhi Rd Cincinnati ohio45238

3rd location
( coming soon )

Dayton

665 East Dublin Granville Rd

Call us today

665 East Dublin Granville Rd

Call us today

Schedule Wheelchair Transport

Please Provide Face Sheet For Patient

Facility Payment Agreement

Quick Links

Our Services

Get In Touch

2212 WILSON RD, COLUMBUS OHIO 43228

6145928223

info@primecareems.com

Quick Links

Get In Touch

Phone Number

Fax Number

Email

1st Location

2nd Location

3rd location
( coming soon )

4852 Delhi Rd Cincinnati ohio45238

2024 cleveland Cincinnati

Follow Us

Copyright © 2023 · PrimeCare Ambulance Services LLC · Website Design by SpringHive

Schedule A Transport

665 East Dublin Granville Rd

Call us today

665 East Dublin Granville Rd

Call us today

Schedule Wheelchair Transport

Please Provide Face Sheet For Patient

Facility Payment Agreement

Quick Links

Our Services

Get In Touch

2212 WILSON RD, COLUMBUS OHIO 43228

6145928223

info@primecareems.com

Quick Links

Get In Touch

Phone Number

Fax Number

Email

1st Location

2nd Location

3rd location ( coming soon )

4852 Delhi Rd Cincinnati ohio45238

2024 cleveland Cincinnati

Follow Us

Copyright © 2023 · PrimeCare Ambulance Services LLC · Website Design by SpringHive

Schedule A Transport

3rd location
( coming soon )