NEED-A-LIFT
Premium Wheelchair & Escorted Transportation
Authorization Form
Please fill out completely, along with an authorized signature and fax it to us at
(317) 244-1314
(317) 244-1314
| Request for Transportation provided by Need-A-Lift Phone: (317) 244-1314 Fax (317) 244-3590 Facility Name: ____________________________________________________________________ Contact Name: _______________________________________________________________ Phone: _____________________ Ext#:___________ Fax: ___________________________ Patient Information (Please print clearly) Date of Order_________/_________/__________ Date of Service_________/_________/__________ Pick-up Time ____:__ Appointment Time: _____:_____ Return Time: ______:______ Round Trip: _____ One-way:______ # Steps_______ # of companions: _______ Wheelchair own: ______ ours: regular______ elevating______ wide______ ex-wide______ M___ F___ DOB: _______/_______/_______ approximate weight: _________ Patient’s Name: Last _____________________, First: ________________________________ From: ______________________________________________________Room_________ Destination: _______________________________________________Room___________ Phone: _____________________ Doctor/Medical: ________________________________ Must be completed by authorized person only _____ direct billing (Required signature to guarantee payment must be completed below) Name: ______________________________________________________________ Title ________________________________________________________________ Billing address: _______________________________________________________ Phone: (______) ____________________ ext __________ Fax__________________ Claim /Case Number: ___________________________________________________ I hereby authorized the above transportation for payment. Signature: __________________________________________Date: ________________ NEED-A-LIFT Transportation- 77 S. Girls School Rd. Suite 202, Indianapolis, IN 46231 |
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