Medical Certificate of Transportation

 To be valid, the Attending physician, Physician’s Assistant, Nurse Practitioner, Therapist or other licensed healthcare professional must complete and sign this certification. The least costly and most appropriate means of travel must be utilized.
Note: If Bariatric please indicate Weight and Height below.
Weight/Height
Does the patient own a Vehicle or have a friend, family member, Does patient not own a Vehicle or have a friend, family member, or volunteer who is willing to drive them to and from their medical or volunteer who is willing to take them to appointments? Is appointments?
Does patient not own a Vehicle or have a friend, family member, or volunteer who is willing to take them to appointments? Is the patient able to get into and out of the regular sedan style vehicle?
I affirm that the above statements are true and accurate to the best of my knowledge and federal funds will be used for the service I am requesting on behalf of my patient and the most medically appropriate service is being requested.