Tuesday, October 19, 2021
Use this form for requesting Non-Emergency Medical Transports. (NEMT)
This is a secure form and will submit through a secure process (Secure Socket Layer - SSL) assuring your information is encrypted during transmission.
Please provide as much contact information and double check your information for accuracy.
You may also call or text 1-888-699-2669.
Service requested by:
Special instructions: COVID-19 symptons, Oxygen, DME (Durable Medical Equipment), Droplet: Masks required, Contagions, etc...