Request Medical Transportation Service

For Service Call

(310)537-3971

Request For Transportation

Please fill in all fields to request the scheduling of medical transportation services. All provided information must be verified before dispatching the requested medical transport service.

Type of Transport

Requester Name

Requesting Party

Facility Individual Parent Legal Guardian

Direct Phone Number

Alternate Phone Number

Trip Authorize By (If Requester Is a Facility):

Facility Contact Person Name

Facility Contact Person Direct Phone Number

Patient Information Face Sheet

Patient Name

Pick-Up Date

Pick-Up Time

Trip

One-Way (A-Leg) Round-Trip (A&B-Leg)

From /Facility Name

Street Address

City

Zip

Receiving Facility/Destination

Street Address

City

Zip

Insurance Information:

Responsible Party

Insurance Carrier

Account/I.D.#

Authorization#

Please provide additional information or special precautions.

If your insurance provider is responsible for paying, an authorization number from the insurance carrier must be provided and verified before the dispatching of an ambulance and transport.

FOR SERVICE CONTACT: (310) 537-3971

For Service Call

Request For Transportation

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