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Our Satisfaction Guarateed Policy
If CVS Transportation Services is the cause of the client being late to an appointment, or experiencing longer than expected wait time, there will be no charge for that trip.
Satisfaction Guarantee Policy
Monday, 06 February 2012
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Why Private Shuttle?
Non-Emergency Medical
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Transportation Request Form
Please call if request is submitted less than 24 hours from the pick-up time. Our system will automatically send a confimation email. If you do not receive this email within 5 Minutes, please give us a call at (248) 352-8380 to confirm.
Please enter information for client here
Client Name:
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Who is requesting our service?
Requested By: (*)
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Fax:
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Please enter Case Manager information here
Company:
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Address:
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Please enter Adjuster Information here
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Please enter Attorney Information here
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Pick Up Information
Date Service was Authorized? (*)
You must provide date of authorization!
Appointment Date:
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Appointment Time: (*)
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2:00
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3:00
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3:45
4:00
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4:30
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5:00
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5:30
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6:00
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11:00
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11:45
12:00
12:15
12:30
12:45
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Travel Days:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Client Needs:
Stretcher
Non-Wheelchair
Wheelchair
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Pick Up Location:
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Please include Street Address, City, State, and Zip Code
Destination:
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Special Request:
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Comments:
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Download a PDF Form to save to your computer.
Address:
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State:
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Phone: (*)
Phone number is required!
E-Mail: (*)
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Manager:
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City:
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Zip Code:
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Fax:
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Agent:
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City:
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Zip Code:
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Fax:
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Claim Number:
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Adjuster:
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City:
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Zip Code:
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Fax:
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Attorney:
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City:
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Zip Code:
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Fax:
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AM or PM?
AM
PM
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