Health Plus Trans - Service Request Form

Health Plus Trans - Service Request Form

Is this service requested within one business day of the appointment?*

Yes

Will this service begin before 8:00 AM or end after 5:00 PM local time?*

Yes

Is this service scheduled for a Saturday or Sunday?*

Yes

Is this service scheduled on a federal holiday?*

New Year's Day (January 1)
Birthday of Martin Luther King, Jr. (Third Monday in January)
Inauguration Day (January 20, every 4 years following a presidential election)
Washington's Birthday (Also known as Presidents Day; third Monday in February)
Memorial Day (Last Monday in May)
Juneteenth National Independence Day (June 19)
Independence Day (July 4)
Labor Day (First Monday in September)
Indigenous Peoples Day (Second Monday in October)
Veterans Day (November 11)
Thanksgiving Day (Fourth Thursday in November)
Christmas Day (December 25)

Yes

What email should confirmations and updates regarding staffing be sent to?*

Bill to:*

If the payor is not on this list, please fill in entity information including business name and accounts payable contact.

Select or enter value

Claims Adjustor or Responsible Party (Billing Contact)*

Please include name and best contact number

Claim Number or Identifying Reference Number*

Purchase Order Number (if applicable)

Who is the client?*

Format: LAST, FIRST (please and thank you!)

Claimant Date of Injury

This is required upon initial intake but may be skipped if we have provided services for this claimant before.

What language does the client use primarily?

Select or enter value

Please be advised that per our various contracts, interpreters are scheduled for two hours unless explicitly requested by the claim adjuster on the file. Our interpreters are not instructed to nor obligated to stay past their scheduled time.

For on-demand telephonic interpreting 24/7/365, please call our proprietary line at (844) 423-5425 with a claim or reference number.

Type of Certification Needed*

Qualified

Medical Certified

Legal

Conference

Pick up Address*

Please include unit number (if applicable) for easy identification

Pick up State*

Select

Location 1Address*

Please include facility or doctor’s name and suite number for identification

Location 1 State*

Select

Does this request include returning the claimant back to their original pick up address?*

Yes, and there is only one appointment

Yes, and there are multiple appointments/stops

No, they will need to be dropped off somewhere else after their appointment(s)

No, this is a one way only

Location 2 State

Select

Location 3 State*

Select

Location 4 State*

Select

Location 5 State*

Select

Location 6 State*

Select

Please list any other location(s) the claimant will need transport for*

Is wait time approved?*

Yes

Please be advised that wait time is recommended for any trip longer than one (1) hour between pick up points or if there are multiple destinations/stops

Does the client use a mobility aid?*

If yes, please describe- walker, knee scooter, crutches, a cane, etc

Are there stairs at the pick up/drop off location?*

If yes, how many? An additional crew member may be required for safety purposes

Please provide the client's height and weight*

Clients who weigh more than 250 lbs are considered bariatric and will require an additional crew member to assist

Client's Date of Birth

When is the Service Needed?*

Please select the time zone for the service*

EST

MST

PCT

Assignment Arrival/ Pick up time*

Approximate End Time*

May be an estimate. This gives us an idea of the anticipated duration of the assignment

Is this a recurring service for the same client and location?*

If yes, please list the dates and times of follow-up appointments so we may add them to our schedule

Client's Contact Number (mobile, if possible)*

Please provide a valid contact number will that may be used for confirmations and coordination regarding this service

Phone

Any other person(s) who are authorized to communicate with our office regarding this service

This can be a spouse, sibling, adult child, a case manager, an attorney, a parole officer, whoever else is authorized to receive communications and confirmations about this service!

Names, contact numbers, and email addresses are appreciated!

Link to access virtual platform*

If we are hosting the call, please indicate that HPT will provide the link

Please briefly describe the documents to be translated*

Does the client consent to receive automated text messages for confirmations to the contact number provided?*

Yes

By selecting "Yes," you confirm that the client is consenting to receive automated SMS message confirmations. Message rates may apply.

Any additional information we need to know about?

Documentation*

Please upload any supplemental documents we may need (Purchase Order, FROI, depo notice, appointment letter, etc)

Drag and drop files here or

Send me a copy of my responses

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