Premium Wheelchair & Escorted Transportation Services

Now Offering Wheelchair Accessible Limousine Services
Authorization Form
Please fill out completely, along with an authorized signature and fax it to us at
(317) 244-1314
Request for Transportation provided by Need-A-Lift
Phone: (317) 244-1314         Fax (317) 244-3590

Facility Name: ____________________________________________________________________

Contact Name: _______________________________________________________________        

Phone: _____________________ Ext#:___________ Fax: ___________________________

Patient Information (Please print clearly)

Date of Order_________/_________/__________ Date of Service_________/_________/__________

Pick-up Time ____:__ Appointment Time: _____:_____ Return Time: ______:______

Round Trip: _____ One-way:______ # Steps_______ # of companions: _______

Wheelchair own: ______ ours: regular______ elevating______ wide______ ex-wide______

M___ F___ DOB: _______/_______/_______ approximate weight: _________

Patient’s Name: Last _____________________, First: ________________________________

From: ______________________________________________________Room_________

Destination: _______________________________________________Room___________

Phone: _____________________ Doctor/Medical: ________________________________

Must be completed by authorized person only _____ direct billing
(Required signature to guarantee payment must be completed below)

Name: ______________________________________________________________

Title ________________________________________________________________

Billing address: _______________________________________________________


Phone: (______) ____________________ ext __________ Fax__________________

Claim /Case Number: ___________________________________________________

               I hereby authorized the above transportation for payment.

Signature: __________________________________________Date: ________________

NEED-A-LIFT Transportation- 77 S. Girls School Rd. Suite 202, Indianapolis, IN 46231
NEED-A-LIFT               -or-                NEED-A-LIMO