STAT Emergency Medical Service

Health Plus Scheduling Services
Schedule your Health Plus non-emergency transport ambulance, wheelchair, or cab services by filling out the form below. Thank you!

Fields marked with * are required.

Person Requesting Services*:
Contact Phone*:
E-Mail*:
Patient First Name*:
Patient Last Name*:
Patient Date of Birth*:
Recipient Number*:
Pick Up Location*:
Pick Up Time*:
Destination Name*:
Destination Address*:
Destination Time*:
Date of Appointment*:
Ambulance, Wheelchair or Cab:	Ambulance Wheelchair
	Cab None
Is the patient a minor?*	Yes No
Is anyone riding along?*	Yes No
Please list any special equipment requirements. (i.e. oxygen, leg rest, etc.)

Physician Certified Statements

Click here for your Physician Certified Statement (Non-Emergency ambulance only).

PCS forms are required for all non-emergent ambulance transportation. If you cannot print this form we are able to fax you the form at your convenience.

If a cab is needed the patient must have a written script from their doctor explaining why they cannot use public transportation.

If you are unable to complete any field on this form indicate N/A and a patient support representative will follow up with you.

If your need is sooner than 24 hours in advance, please contact us @ 888-676-1783 and a patient support representative will assist you immediately.

A STAT EMS Patient Services representative will contact you shortly to confirm your on-line scheduled appointment.

Hear what some of our customers are saying about STAT EMS!

*Pam Dycus, PA for Evergreen Health Care says,

"STAT EMS is very professional and courteous".

*Charlene, Davison DaVita says,

"I love STAT. They are the BEST company to work with".

*Christian, Fenton DaVita says,

"All STAT crews are professional and friendly"