Healthcare Facilities Medi Trans CTN Louisiana Transportation

Louisiana Healthcare Professionals

MediTrans understands that communicating with facilities and healthcare professionals is crucial to positive outcomes for members. With this in mind, we have multiple ways to keep in touch with us about member’s transportation needs.

You can contact us at 1-844-349-4324 or facility@meditrans.com to schedule, modify, or get status updates on member’s trips.

You can also setup Standing Orders for members by completing and returning the PDF below, or simply using the webform below to submit the information electronically.

Standing Order Transportation Request Form

Reoccurring appointments with same pick-up and drop-off times, at least once a month for 6 months, or 1 or more times per week for 4 or more weeks.

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender (Select One)*
Medicaid ID Number*
Member's Phone Number*
Alternative Phone Number
Requester's Name*
First Last
Requester's Relationship to Patient*
Requester's Contact Number*
Requester's Email
Appointment Reason*
Appointment Time*

: Hours

Minutes
Return Pickup Time*

: Hours

Minutes
Appointment Start Date*
MM slash DD slash YYYY
Appointment End Date*
MM slash DD slash YYYY
Appointment Days of Week (check as many boxes as needed)*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Member's Mobility Status (select one)*
Notes / Comments
Home / Pickup Address*
Street Address Address Line 2 City State ZIP Code
Special Directions
Facility / Drop Off Address*
Street Address Bldg/Floor/Apt/Suite City State ZIP Code
Special Directions
Facility Phone Number*
Additional information (Check all that apply)
- The Member lives 1/4 of a mile from a bus stop, the facility is 1/4 of a mile or less from a bus stop, and the Member can physically walk to and from the bus stop before and after appointments. (In this case, a monthly bus pass will be issued to the Member)
- The Member has a friend or family member that is willing to bring them to/from the appointments and be reimbursed through the Gas Reimbursement Program
- The Member does not qualify for Public Transportation or Gas Reimbursement
Signature*

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