Non-Emergency Transportation Request

Note: Fields marked with an * indicates required field

If you have not completed a transportation survey within the past year you must contact Customer Service at 888-327-0671 before you can use this form.

To use this form you MUST submit 24 hours or more before your appointment for appointments within 30 miles of your home and 48 hours or more for appointments over 30 miles from your home. For transportation over 30 miles from your home, a letter of medical necessity may be required. Urgent same day requests must be requested by calling Customer Service at 888-327-0671 (TTY:711).

As a reminder McLaren Health Plan only covers transportation for services covered by MHP.

All Fields Must Be Completed

Enter First Name: *

Enter Last Name: *

Enter Date of Birth (xx/xx/xx): *

Enter Member identification Number (found on Card) or
Social Security Number if Member ID is unknown): *

Enter Address(this is where you will be picked up - must match our system): *

Enter City: *

Enter State: *

Enter Zip: *

Enter Phone Number (XXX-XXX-XXXX):*

Enter Email Address:

Select Type of Appointment (Chemo or dialysis please contact Customer Service): *

If Other, please specify:

Enter Date of Appointment (xx/xx/xx): *

Enter Time of Appointment: *

Enter Name of Provider: *

Enter Appointment Address: *

Enter Appointment City: *

Enter Appointment State: *

Enter Appointment Zip: *

Enter Phone Number of Provider (xxx-xxx-xxxx): *

Will you need a pharmacy stop? *

YesNo

Name of Pharmacy:

Enter Pharmacy Address:

Enter Pharmacy City, State, Zip:

Additional riders (you must provide your own appropriate car seat for children under 48 inches)? *

YesNo

Do you use a wheelchair that requires a wheelchair lift? *

YesNo

McLaren Health Plan Non-Emergency Transportation Request

Non-Emergency Transportation Request

McLaren Health Plan
Non-Emergency Transportation Request