Facility Partnership Inquiry

For hospitals, dialysis centers, skilled nursing facilities, assisted living communities, rehabilitation centers, outpatient clinics, care coordinators, and healthcare or senior-care partners. Complete this form and a member of Element NEMT will follow up personally.

Element NEMT provides non-emergency transportation only. If this is an emergency, call 911.

Element NEMT works with healthcare facilities, senior-care communities, treatment centers, and care coordination teams that need dependable non-emergency transportation support. Please complete this short inquiry form and a member of Element NEMT will follow up personally.

Please do not submit patient medical information, diagnosis information, Social Security numbers, insurance details, or private health information through this form. This form is for facility partnership and transportation coordination inquiries only.

Facility Information

Facility Name*

Facility Type*

Facility Address*

City*

State*

ZIP Code*

Main Facility Phone*

Facility Website

Primary Contact

Primary Contact Name*

Title / Role

Department

Direct Phone Number*

Email Address*

Best Method of Contact

Best Time to Contact

Transportation Needs

What type of transportation support are you interested in?

Estimated Transportation Need

Current Transportation Challenge or Reason for Inquiry

Additional Notes or Questions

Required Acknowledgments

I understand this form is for facility partnership and transportation coordination inquiries only and should not be used to submit patient medical information or emergency requests.

I understand that Element Non-Emergency Medical Transport provides non-emergency transportation only and does not provide ambulance transport, emergency response, medical treatment, or 911 services.

Fields marked * are required. A member of Element NEMT will follow up personally.

Requesting a Ride for Yourself or a Family Member?

Private-pay clients, families, and caregivers should use the patient transportation request form.

Request Transportation →

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