Transportation Program Application – ALS United of Georgia

Client Name:

First Last

Address:

Street Address City State / Province / Region ZIP / Postal Code

Phone:

Email:

Adult Accompanying Client:(Required)

First Last

Relationship:

Phone:

Please choose either VAN RENTAL REQUEST, NON-EMERGENCY TRANSPORT REQUEST or FINANCIAL ASSISTANCE REQUEST below.

Request Type

VAN RENTAL REQUEST

DOOR-TO-DOOR NON-EMERGENCY TRANSPORT REQUEST

FINANCIAL ASSISTANCE REQUEST

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Van Rental Request

VAN RENTAL REQUEST

Indicate number of days for rental:

Dates for rental:

Purpose of rental request:

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Door-to-Door Non-Emergency Transport Request

DOOR-TO-DOOR NON-EMERGENCY TRANSPORT REQUEST

A companion is required to ride and remain with the client on all non-emergency transport requests.

Transport Purpose:

Choose all that apply:

ALS Clinic, Doctor's Appointment

Social Activities (ex. Chapter Event, Church, Party Events, Movies, Shopping, Outing)

Appointment Date

Appointment Time

Pick Up Location:

Street Address City State / Province / Region ZIP / Postal Code

Pick Up Location Phone Number:

Drop Off Location:

Street Address City State / Province / Region ZIP / Postal Code

Drop Off Location Phone Number:

Please indicate type of accommodation currently used:

Choose all that apply:

Power Wheel Chair

Able to ambulate, routine transport

Transport Chair/Manual Wheelchair

Stretcher

Financial Assistance Request - Vehicle Adaptations OR Van Voucher:

(check appropriate box and include a written statement below)

Van/Car Adaptations

Van Voucher

Written Statement:

Please provide details for financial assistance (ex. Purchase of Van, vehicle modifications required, etc.)

Guidelines

Transportation request must be submitted at least 2 (two) weeks in advance of appointment or rental.
pALS must be accompanied by a caregiver.
Cancellations must be received 48 hours prior to scheduled pick-up or pALS may incur a cancellation fee (cancellation fee to be disclosed at time of scheduling).
If the appointment is cancelled by the medical provider, pALS must provide documentation of such to eliminate cancellation fee responsibility.
pALS are prohibited from arranging transportation without approval of program coordinator under this program. (Authorization code will be given at the time of approval)
Each transport requires pre-approval and a unique Authorization code.
Utilizing the van rental option, all pALS/cALS must adhere to the legal ramifications governing van rentals in the state of Georgia as well as honor stipulations set forth by the van company.

By agreement with the ALS United of Georgia, I understand that if approved for The Paul Williams ALS Transportation Program, services will be provided by a third-party transportation provider. I authorize the Program Coordinator to release and obtain any information necessary to complete this referral.

By signing below, I also acknowledge that the ALS United of Georgia, Inc., is not a provider of medical or transportation services, and is only arranging for transportation services by a third-party provider. ALS United of Georgia will not be providing medical or transportation services of any kind. As such, by signing below you hereby agree to release and hold harmless the ALS United of Georgia from any legal claims or causes of action you, or any party related to you, may have arising out of the negligence or other actions of the third-party transportation provider.

Client Signature(Required)

Date(Required)

Signature of Adult Accompanying Client:(Required)

Date(Required)

The Paul B. Williams Transportation Application

The Paul B. Williams ALS Transportation Program Application

Guidelines