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NEMT Brokerage Referral Form

Keval Brokerage Transit — Non-Emergency Medical Transportation

Complete all sections. Print, sign, and fax to the number at right.

Keval Brokerage Transit
2304 Porter Rd, Bear, DE 19701
Phone: (302) 289-5959
Email: [email protected]
FAX: (302) 556-3465
CONFIDENTIAL — PROTECTED HEALTH INFORMATION
This form contains protected health information (PHI) subject to HIPAA privacy regulations. It is intended solely for the use of Keval Brokerage Transit and the authorized referring provider. Unauthorized disclosure is prohibited. Fax only to (302) 556-3465.
Section 1 — Referring Provider / Facility
Section 2 — Patient Information
Male Female Other
Section 3 — Insurance & Funding Information
Medicaid Medicare Private Insurance Self-Pay Other:
Section 4 — Medical Necessity & Diagnosis
Ambulatory (walks independently) Uses Cane / Walker Wheelchair (manual) Wheelchair (power) Stretcher Other:
Oxygen required Attendant / escort required Bariatric vehicle needed Non-English speaking Behavioral considerations
Section 5 — Trip Details
One-time Recurring
Yes No
Section 6 — Referring Provider Certification

I certify that the above-named patient requires non-emergency medical transportation and that the information provided is accurate and complete to the best of my knowledge. I authorize Keval Brokerage Transit to coordinate transportation services on behalf of this patient.

For Office Use Only — Do Not Complete
Keval Brokerage Transit — 2304 Porter Rd, Bear, DE 19701 — (302) 289-5959 FAX COMPLETED FORM TO: (302) 556-3465 Rev. August 2026 — Page 1 of 1