Healthcare Transportation Partnership Application

Who Can ApplyHospitals, dialysis centers, nursing facilities, rehabilitation centers, assisted living communities, case management teams, and other healthcare partners.

Transportation ServicesAmbulatory, wheelchair, stretcher, recurring appointments, dialysis, rehabilitation, and discharge transportation.

Next StepsOur team reviews your application and contacts you regarding service needs, scheduling, billing, and onboarding.

Organization Information

Tell us about your facility or organization.

Organization Name *

Facility Type *

Facility Address *

City *

State *

ZIP Code *

Organization Website

Primary Contact

Who should we contact about the partnership?

Contact Name *

Title / Role *

Phone *

Email *

Preferred Contact Method *

Billing Information

Optional if different from the primary contact.

Billing Contact

Billing Email

Preferred Billing Arrangement

Transportation Needs

Help us understand your expected transportation needs.

Transportation Needs *

Estimated Trip Volume *

Recurring Transportation?

Primary Service Area

Requested Start Date

Current Transportation Provider

Special Requirements / Additional Information

Additional Information

How did you hear about Legacy 1115?

I certify that I am authorized to submit this partnership inquiry on behalf of the organization listed above. I understand that submitting this application does not create a contract or guarantee transportation availability. Any partnership or service arrangement is subject to review and written approval by Legacy 1115 Transportation.

Questions or prefer email? Contact info@legacy1115transport.com.