Schedule Non-Emergency Patient Transportation


Scheduling your patient transportation is easy.  Complete the form below and you will receive confirmation within 60 minutes or less. 

STAT is licensed to provide ambulance patient transportation anywhere in the State of Michigan. 

Person Requesting Services:
Contact Phone:
Contact Fax:
E-Mail:
Patient First Name:
Patient Last Name:
Patient Date of Birth:
Pick Up Location:
Pick Up Time:
Destination Location:
Destination Time:
Date of Appointment:
Ambulance or Wheelchair:
Ambulance   Wheelchair
Is the patient in your PPS stay?
Yes   No
Primary Insurance Carrier:
Policy/ID Number:
Group Number:
Subscriber Name:
Subscriber Date of Birth:
   
     
     
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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 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 @ 810.233.4400 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.

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