Request Wheelchair Transportation Services- Complete the Intake Form Below

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PATIENT DEMOGRAPHICS

Patient Name *

First

Last

Patient Phone #

Patient Weight

Patient Address

DISCHARGES Name Time

INTAKE CONTACT PERSON

Caller Name

Caller Phone #

Relationship to Patient

TRANSPORTATION ORDER

Date of Transportation

Pick - Up Time

Return Time

Waiting Time (If Applicable)

HOSPITAL DISCHARGES

Hospital Entrance

Hospital Room #

Hospital Bed #

Discharge Nurse Name

Discharge Nurse #

WHEELCHAIR NEEDED

Select Choice Below

• Yes
• No

PAYMENT TYPE

Select Payment Type

• Private Pay
• M.A.S.
• Contract

Best Email or Phone for Billing

NOTES

Submit

Action Transportation provides reliable non-emergency medical and wheelchair- accessible transportation throughout the capital region and surrounding areas. We accept Medicaid and work with eligible transportation services across New York State. We also offer private pay transportation options for approved medical and accessibility needs. We accept Medicaid transportation arranged through MAS, as well as private pay. In some cases, we also work with select insurance providers. Please contact our dispatch office for questions regarding coverage, eligibility, or scheduling.

Our team is available to assist with:
-Medical Appointments
-Hospital Discharges
-Long-distance transportation
-Wheelchair accessible transportation
-Scheduling and transportation questions.

We are available Monday through Saturday, including most holidays. Our dispatch office is happy to assist with quotes, scheduling, and transportation questions.