NEMT Intake Form

MedHaul is a Certified B Corporation. Read more about what that means here.

MedHaul NEMT Provider Intake Form

Upon completion of this form, a member of our team will connect with you to discuss a potential partnership with MedHaul.

Company Name*

Contact Name and Title*

Company Address*

Email Address

Phone Number*

What state(s) do you service?*

Service Area Zip Codes

Ride Types Offered*

Select all that apply.

Ambulatory with assistance

Ambulatory with no assistance needed

NEMT Ambulance

Stretcher - bariatric (over 400 lbs)

Stretcher - non bariatric (under 400 lbs)

Wheelchair - bariatric (over 400 lbs)

Wheelchair - non bariatric (under 400 lbs)

Ride Accommodations Your Company Provides*

Select all that you/your company have on hand to bring to riders as part of their transport.

Car seat

Stretcher

Stretcher - bariatric (over 400 lbs)

Walker

Wheelchair

Wheelchair - bariatric (over 400 lbs)

Wheelchair (motorized) - we DO provide equipment for stairs

Wheelchair (motorized) - we DO NOT provide equipment for stairs

Other

Total # of Drivers*

The total number of drivers in your fleet.

Fleet Size*

Example: 0 ambulance, 2 stretcher vehicles, 7 wheelchair vans, 5 regular cars

How are your ride requests managed?*

Select all that apply.

Dispatchers assign drivers, communicate with drivers via devices, DISPATCHERS manage rides from the office

Dispatchers assign drivers, communicate with drivers via devices, DRIVERS manage rides from their devices

Drivers get direct notification of ride request via devices, drivers accept & manage rides from their devices

Other

Ride scheduling options*

Select all that apply.

On-demand (same day)

Scheduled (next day or further out)

For on-demand or same day rides, what is the typical window between request and pick-up that you communicate with clients and riders? *

Covid-19 Transport*

Select all that apply.

Transport to/from Testing Sites only

Transport to/from Vaccination Sites only

Transport confirmed cases

Not interested

Thank you! The MedHaul team will be in touch shortly.

Your response has been recorded. A member of our team will reach out via email to follow-up. Thank you!

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