Clinical & Appointment Transport Packet
Clinical & Appointment Transport Coordination
Welcome! Use this portal to establish recurring appointment transportation schedules or submit Physician Certification Statements (PCS) for non-emergency medical transportation (NEMT). Select an option below to submit online or download printable forms.
Online Digital Form Submissions
Best For: Clinic Schedulers, Receptionists, and Case Managers setting up standing appointment schedules (e.g., Dialysis, Radiation, Chemo, Physical Therapy).
What You’ll Need: Patient DOB, treatment days/times, clinic address, and optional ICD-10 codes.
Best For: Attending Physicians, RNs, Case Managers, NPs, or PAs certifying medical necessity and mobility requirements.
What You’ll Need: Primary/Secondary ICD-10 diagnosis codes, functional capacity selection, and the ordering physician’s NPI.
Recurring Medical Transport & Visit Log
PDF Downloads & Paper Forms
Physician Certification Statement
Includes Cover Sheet, RTL-2026, and PCS-2026
Standing Schedules:
Submitting Form RTL-2026 permanently reserves the patient's recurring trips in our dispatch engine. Please notify dispatch at least 2 hours prior to any treatment cancellations.
Submitting Signed Paperwork
You can email scanned or printed copies to info@sameltransitsolutions.org, send them back with your patient, or upload them via our portal.