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Patient Transportation Authorization

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

Section 1 — Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Phone Number *

Alternate Phone

Preferred Language

Home Address *

City, State, ZIP

Section 2 — Insurance & Coverage

Insurance / Payer Name *

Member ID / Medicaid ID *

Group Number (if applicable)

Authorization / Prior Auth Number

Coverage Type

Medicaid Medicare Private Insurance Self-Pay Other:

Section 3 — Transportation Needs

Mobility / Equipment Needs

Ambulatory Cane / Walker Wheelchair (manual) Wheelchair (power) Stretcher

Special Accommodations

Attendant / escort traveling with patient Oxygen required Bariatric vehicle needed Interpreter needed

Additional Notes on Transportation Needs

Section 4 — Trip Information

Pickup Address *

City, State, ZIP

Pickup Time

Destination / Facility *

Destination Address *

Appointment Time *

First Trip Date *

Return Trip Needed?

Yes No

Estimated Return Time

Recurring Service?

One-time Recurring

If Recurring — Days / Frequency

Section 5 — Patient / Guardian Authorization

By signing below, I authorize Keval Brokerage Transit to arrange and coordinate non-emergency medical transportation services on my behalf (or on behalf of the patient named above). I understand that:

1. My personal and insurance information will be used solely to arrange and bill for transportation services and will be kept confidential in accordance with HIPAA regulations.

2. I am responsible for notifying Keval Brokerage Transit of any cancellations at least 24 hours in advance. Repeated no-shows or late cancellations may affect future service eligibility.

3. Transportation services are non-emergency in nature. In the event of a medical emergency, I should call 911.

4. I have the right to revoke this authorization at any time by submitting a written request to Keval Brokerage Transit.

Patient / Guardian Signature *

Printed Name *

Date *

Relationship to Patient (if guardian)

Guardian Phone Number

For Office Use Only — Do Not Complete

Date Received

Received By

Case / Trip ID

Authorization Verified

Yes Pending No

Assigned Driver / Vehicle

Notes