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					                                     Urgent Ambulance Service Inc.
                                   EDS Transportation Service System
          Wheel Chair / Ambulance
               Date of Transport
                  Pick up Time
               Appointment Time

                 Patients Name
                        SS #
                        DOB
                Pick up Address
                Apt. # or Room #
                        Wing

              Destination Address
                Apt. # or Room #
                        Wing

   Reason for transport/Chief complaint
                       History
                 Special Needs
                   Comments:
            (stairs / weight / other)

                    Billing Info
   please enter appropriate payment source here

        If private patient billing is requested

     please include a complete billing address

          all major credit cards accepted

        (please call for credit card payment)

I acknowledge the information above is accurate and correct to the best of my knowledge. I
understand that wheel chair transportation is not covered by most insurance carriers. If for any
reason the insurance carrier or other provided sources of payment denies payment for any reason,
I understand that the facility I represent will be responsible for any and all unpaid balances
associated with this transportation.

                                       Name/Title:

                                           Phone #:

                                         Signature:

           confirmed by dispatcher
                   Date / Time

    Please print and fax to Urgent Ambulance @ 302-454-1837 Then call to confirm the approval
       Arbors
        BMA
    Ch Dialysis
     CH Hosp
      Hillside
  Hockesin Hills
     Kentmere
    Laurelwood
     MC Foulk
      MC Pike
      Millcroft
     Parkview
  Riverside ECP
        RTC
      Shipley
     St Francis
St Francis Dialysis
     Sunbridge
  Tilton Terrace
        UPD
       WCC
   Wilm Dialysis
    Wilm Hosp

      Other

				
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posted:11/17/2011
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