The information obtained in this certification will only be used for the provision of Central Transportation specialized transportation services.
Otherwise known as Medicaid, Title XIX or MA. Not to be confused with Medicare.
(Please check all that apply)
(Please note, individuals using mobility devices that exceed 30” in width and/or 48” in length may not be able to be accommodated. Also in situations where the applicant and their mobility device have a combined weight of more than 800 lbs. when occupied, Central Transportation may not be able to accommodate the ride.)
In order for your application to be evaluated, it may be necessary to contact a physician or other professional to confirm the information you have provided. Please complete the following information and authorization form.
Registered Nurse, Case Manager, Rehabilitation Professional, Physical Therapist, Occupational Therapist, Mental Health Professional.
This field is not part of the form submission.
* indicates a required field