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NON-MEDICAL TRANSPORTATION REQUEST From This program is funded by the Long Term Care Ombudsman Program and Administered by the Connecticut Agencies on Aging THIS COMPLETED FORM SHOULD BE FAXED TO

How to fill out non medical transportation request

How to fill out a non medical transportation request:

1. Start by obtaining the necessary form or request document from the appropriate organization or agency. This may be available online or at a local office.
2. Fill in your personal information accurately and completely. This may include your name, contact information, address, and any other details that are required.
3. Provide the specific details of the transportation request. Indicate the date and time of when the transportation is needed, as well as the pick-up and drop-off locations.
4. Explain the purpose of the transportation request. Whether it is for a medical appointment, therapy session, or any other non emergency medical-related reason, clearly state the purpose to ensure appropriate transportation arrangements.
5. Include any additional information or special requests. If you have any specific preferences or requirements, such as the need for a wheelchair-accessible vehicle or if you will be accompanied by a caregiver, make sure to note these details.
6. Read through the filled-out form or request thoroughly to ensure accuracy and completeness. Double-check for any errors or missing information.
7. Sign and date the form to certify that the information provided is true and accurate. Failure to sign the form may delay the processing of the request.
8. Submit the completed form to the appropriate agency or organization either online, through mail, or by personally delivering it to the designated location.

Who needs non medical transportation request:

1. Individuals with mobility limitations: Non medical transportation requests are often needed by individuals who have difficulty walking, using stairs, or driving due to physical disabilities or health conditions.
2. Seniors: Older adults who may no longer be able to drive or have limitations in using public transportation often require non medical transportation services for reaching medical appointments, running errands, or attending social activities.
3. Patients requiring specialized care: Individuals undergoing medical treatments or therapies that render them unfit to drive may require non medical transportation services to get to and from their appointments.
4. Individuals without access to personal transportation: Some individuals may not own a vehicle or have access to public transportation, making non medical transportation necessary for them to fulfill their transportation needs.
5. Individuals with temporary injuries or illnesses: Those with temporary conditions, such as a broken leg or recovering from surgery, may require non medical transportation until they regain their mobility.

Remember to always consult the specific guidelines and requirements of the organization or agency providing non medical transportation services to ensure that you provide the necessary information when filling out the request.

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What is non medical transportation request?

A non medical transportation request is a form that needs to be filled out to request transportation services for individuals who do not require medical care during the trip.

Who is required to file non medical transportation request?

Non medical transportation requests may be filed by individuals or organizations on behalf of someone who needs transportation services.

How to fill out non medical transportation request?

To fill out a non medical transportation request, one must provide information such as the pick-up and drop-off locations, date and time of transportation needed, and any special accommodations required.

What is the purpose of non medical transportation request?

The purpose of a non medical transportation request is to ensure that individuals who do not require medical care during transportation have access to safe and reliable transportation services.

What information must be reported on non medical transportation request?

Information that must be reported on a non medical transportation request includes contact information, transportation needs, and any special accommodations required.