MedTrans Go Private Pay Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

While MedTrans Go is a Business-to-Business platform, we understand individuals may need transportation and interpretation services to receive the medical care they need. If you would like to submit a private request for our services, please fill this form out in full. Once you submit this form, a member of our Operations team will call you for this information.

All information goes directly to a secure data storage location only accessible to MedTrans Go employees with HIPAA-compliance training.

For any questions regarding the process, please email requests@medtransgo.com or call 404-826-7212.

Your Name (First and Last Name) *

Your Phone Number *

Your Email *

Your relation to the patient seeking our services: *

Parent

Daughter/Son

Spouse

Medical Provider

I am the patient

Other:

Do you work at a medical facility or healthcare provider and are looking to arrange transportation or interpretation for a patient of your facility? *

Yes

If yes to the previous question, please list the name of the facility/provider:

Patient and Service Information

Please fill out the rest of the form with information regarding the patient seeking MedTrans Go services. If you are the patient seeking our services, please fill out your information again.

Patient Name (First and Last Name) *

Patient Phone Number *

Patient Email *

Type of Request *

Transportation

Interpretation

Clear form

Never submit passwords through Google Forms.

This form was created inside of MedTransGo.com. Report Abuse

Forms