Insurance Coverage Review

Before you submit

Our team will review your insurance benefits, coverage limitations, prior authorization requirements, and medical necessity documentation before transport. Verification does not guarantee coverage or payment. If transportation is not covered, we can discuss private-pay options. Submitting this request does not confirm a booking. Please do not include Social Security numbers or payment card details. For transport coordination, call 979-559-2961. This form is not for emergencies; call 911 for emergency care.

Patient and contact details

Patient full name

Enter the name shown on the insurance card.

Patient date of birth

Use the patient’s date of birth.

Contact name

Person our team should contact about this request.

Relationship to patient

For example: self, family member, caregiver, or facility staff.

Contact phone number

Include area code.

Contact email address

Optional: an address where our team can contact you.

Requested transport date

If known. Our team will confirm availability.

Transport purpose and assistance needs

Optional: reason for the trip, mobility limitations, and assistance needed. Our team may request supporting medical documentation.

Planned pickup location

If known: facility or residence name and full address, including city, state, and ZIP code.

Planned destination

If known: facility or residence name and full address, including city, state, and ZIP code.

Primary insurance

Primary insurance company

Enter the insurer or health plan name.

Primary member or policy ID

Enter the full ID exactly as shown on the card.

Primary group number

If shown on the card.

Primary policyholder full name

Include the policyholder name even if the patient is the policyholder.

Primary policyholder date of birth

Date of birth of the person who holds this policy.

Patient relationship to primary policyholder

For example: self, spouse, child, or other.

Primary insurance card - front Upload a clear photo or PDF of the front of the primary insurance card. If unavailable, our team will follow up.

Add file

Please upload a file

Primary insurance card - back Upload a clear photo or PDF of the back of the primary insurance card.

Add file

Please upload a file

Secondary insurance (optional)

Secondary insurance company

Complete only if the patient has a secondary policy.

Secondary member or policy ID

Enter the full ID exactly as shown on the secondary card.

Secondary group number

If shown on the secondary card.

Secondary policyholder full name

Enter the name of the person who holds the secondary policy.

Secondary policyholder date of birth

Complete only if there is a secondary policy.

Patient relationship to secondary policyholder

For example: self, spouse, child, or other.

Secondary insurance card - front Upload a clear photo or PDF of the front of the secondary insurance card, if applicable.

Add file

Please upload a file

Secondary insurance card - back Upload a clear photo or PDF of the back of the secondary insurance card, if applicable.

Add file

Please upload a file

Your information will be encrypted.