Transportation Request Form

Nonemergency transportation is a covered benefit for Peoples Health Secure Health (HMO-POS D-SNP) and Peoples Health Secure Complete (HMO-POS D-SNP).

Please complete the form below to request nonemergency transportation. Fields marked with an asterisk (*) are required.

Transportation requests should be submitted at least three business days in advance of your scheduled appointment. You may request transportation between your home and a plan-approved location, such as a network doctor’s office, diagnostic center, lab facility or dialysis center, within 40 miles of your home. Transportation is available Monday through Friday, from 8 a.m. to 5 p.m. Availability to provide transportation for early morning or late afternoon appointments varies. Weekend and holiday service is not available.

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Transportation Request

1Please enter your information below.

2Please confirm the information is correct and click submit.

1. Member Information
Name*
First Last
Member ID*

This number is printed on your plan ID card and starts with a "G"
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Please include area code.
Email*
2. Appointment Information
Physician or provider name:
Address of appointment location*
Street Address Address Line 2 City State ZIP Code
Appointment Date*
MM slash DD slash YYYY
Appointment Time*

: Hours

Minutes

AM/PM
Type of transportation needed:*
3. Additional Information
Are you able to get in and out of a car or van on your own without assistance?*
- Yes
- No
Will you be traveling with a cane, walker or foldable manual wheelchair?*
- Yes
- No
Type of Equipment
Will a guest be traveling with you (guest must be age 18 or over)?*
- Yes
- No
Will you need to fast (not have any food or drink) for the appointment?*
- Yes
- No
Member services will contact you to discuss your request. If your transportation is approved, the driver will contact you the night before your trip to confirm a pickup time. You must be ready when the driver arrives. To stay on schedule, drivers can only wait five minutes. Wait time for pickup from your appointment is up to two hours. If you need to cancel transportation, you must call the Peoples Health transportation department by 5 p.m. on the last business day before the trip or one, one-way trip will be deducted from your annual transportation benefit. The transportation department can be reached at 1-800-659-5910, Monday through Friday, from 8 a.m. to 5 p.m. TTY users may call 711. No shopping bags are allowed.

Transportation Holidays

New Year’s Day

Mardi Gras Day

Memorial Day

Independence Day

Labor Day

Thanksgiving Day

Christmas Day

Transportation Request Form

Nonemergency transportation is a covered benefit for Peoples Health Secure Health (HMO-POS D-SNP) and Peoples Health Secure Complete (HMO-POS D-SNP).

Transportation Holidays

Transportation Request

1. Member Information

2. Appointment Information

3. Additional Information

Transportation Holidays

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