Service Request – Air Ambulance Services and Medical Transportation Services

Download a Service Request form for air ambulance services and medical transportation services in Microsoft Word or Adobe Acrobat format. Complete the form, and fax back to our Call Center at 1-888-777-4799. We are committed to providing reliable and dependable air ambulance services and medical transportation services, and we appreciate your time.

Click to download the PDF version
Click to download the Word Document version

Please fill out the form below for a service request.

If you are scheduling on a Friday, Saturday, or Sunday for a Monday pickup, scheduling multiple visits, or requesting service less than 24 hours before the time of pickup, please contact Med-X directly at 1-888-777-9022. All fields marked with * are required!

Appointment Information

Date of Pickup *
(appointments must be made 24 hours in advance)

Time of Pickup (EST) *
AM
PM
Time of Appointment (EST) *

AM
PM

Return Pickup Time (EST) *

AM
PM

Patient Information

Level of Service Requested *

Ambulance
Wheelchair
Medical Car Service
Air Ambulance
Language Service
Not Sure
Other
If Other (specify here):

Patient Name *

Address *
City *
State *
Zip *
Phone *

Date of Birth(mm/dd/yyyy) *

Gender *
Male
Female
Weight in lbs. *
Social Security Number *

Nature of Injury of Illness *

Pickup Location

Same as Patient Information Above?

Address *
City *
State *
Zip *
Phone *
Room/Location/Dept
(if none leave blank)
Stairs? *

Destination Location

Same as Patient Information Above?

Address *
City *
State *
Zip *
Phone *
Room/Location/Dept
(if none leave blank)
Stairs? *

Insurance Information

Insurance Company *

Address for Claims *
City *
State *
Zip *
Claim # *

Date of Injury (mm/dd/yyyy)

Adjuster or Case Manager *
Adjuster or Case Manager Phone *
Precert Required? *
Yes
No
Precert #
(Required if yes to above)
Type of Claim *

Your Contact Information

Name *

Phone Number *
Fax Number *

Email For Confirmation *

Company *

Any Additional Information We May Need to Know

Comments:

Interested In Our Services?

Please fill out the form below and a service professional will be in touch quickly.

Name (required)
Email (required)
Phone Number
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Med-X Medical | PO Box 720 Matawan, NJ 07747 | Phone: 1-888-777-9022 | Fax: 1-888-777-4799 | International: 1-888-778-9332

© 2012 Med-X Medical Management Services All Rights Reserved.