Broker form – Care Med Dispitch

Service Date

Service Time

Time

Early Pickup Time

Service

Claimant Name:

Weight:

Please enter weight in pounds

Pickup Location

(Location’s name or Address)

Room:

Room number of pickup location

Drop-Off Address

Layout

Please select Suite, Room or Terminal

Number/Name

Dead miles

Trip Distance

This distance is from patient pick-up location to patient drop-off location (in miles)

Trip:

3rd Address

(Location’s name or Address)

Leg Distance

Drop-off -- Drop-off (in miles)

Total Distance

Distance is showing in miles

Wait Time

Rush fee

Click "Yes", If it's a same day service request.

Note:

Requested by

Name

Flat Rate Price: $

No show fee $

Agent name: