Phone Number: (614) 626-0466
Fax: (614) 626-0910

NON EMERGENT

Patient Transport Request Form

PLEASE NOTATE IN THE “REASON FOR TRANSPORT” SECTION IF THIS IS A LOGISTICARE PATIENT

Coverage Information Guide for Carriers that Amerikare Accepts
Insurance
Carrier
Ambulance
Non-Emergent
Ambulance
Emergent
Transfer Discharge Wheelchair Policy
Specific
Co-Pay/Deductible/
Out of Pocket
AARP

Aetna

Aetna Medicare Advantage

Aetna Mycare/ Logisticare

Anthem BCBS

Caresource

Cigna

Humana

Medicaid

Medical Mutual of Ohio

Medicare

Molina

Molina Mycare

Paramount Advantage

* Required Fields

Please provide face sheet for patient



StretcherWheelchairPatient's Wheelchair

We cannot accommodate wheelchairs over 32” wide; most power wheelchairs are not suitable for transport.