Facility Enrollment Form

Facility Information

Primary Contacts

Authorized Ride Requestors

Only the people listed below may schedule, change, or cancel rides unless the facility sends MedBridge a written update.

Service Profile

Passenger Assistance and Equipment

Billing Setup

Required Attachments

MedBridge will request the following after enrollment review:

• Signed Facility Transportation Agreement
• W-9 or vendor registration request (if required by facility)
• Purchase order or billing instructions (if applicable)
• Recurring ride schedule (if applicable)
• Tax exemption or other account documentation (if applicable)

Facility Certification

The facility certifies that the information in this enrollment form is accurate, that listed requestors are authorized to act for the facility, and that the facility will promptly report changes. Enrollment is subject to MedBridge approval and does not guarantee availability for any particular ride.