HIPAA Notice: This form transmits protected health information (PHI) over an encrypted connection. By submitting this form, you confirm that you are authorized to request transportation services for the named patient and that this request is made in accordance with HIPAA regulations. Commonwealth Transport LLC maintains appropriate safeguards to protect PHI in compliance with 45 CFR Parts 160 and 164.
ASAP — first available (same-day ASAP requests only)
Helps us send the right wheelchair van for your patient.
Patient has their own wheelchair
Round trip
A second person is needed to assist (stairs, carrying, heavy transfer)
A second transporter will be included in your price. Please describe the situation (number of steps, hill, etc.) in the notes below.
Return trip will be will-call (patient calls when ready).
All trips from this facility are billed directly to the facility. The patient will not receive a bill.
Patient Billing Information
Any info you can provide helps us bill the patient promptly.
Estimated Cost
This is an estimate only. Actual charges may vary based on traffic, route conditions, and time on scene. Wait time billed at $68/hr per transporter in 15-min increments.
Request Received
You will receive a confirmation email once your transport is confirmed by dispatch.