NEMT Consent Form

Non-Emergency Medical Transportation Consent

By using OVA Dispatch for Non-Emergency Medical Transportation (NEMT) services, you consent to the following:

1. Service Authorization

I authorize OVA Dispatch to provide transportation services to medical appointments, healthcare facilities, pharmacies, and other health-related destinations as requested.

2. Information Release

I authorize OVA Dispatch to share my transportation records with my healthcare providers, insurance companies, Medicaid/Medicare, and transportation brokers as necessary for scheduling, billing, and coordination of services.

3. Appointment Information

I agree to provide accurate appointment times and locations. I understand that late cancellations or no-shows may affect my eligibility for future covered rides and may result in fees.

4. Safety Requirements

• I will wear seatbelts and follow driver safety instructions
• I will inform OVA Dispatch of any special assistance needs
• I understand drivers are not medical professionals and cannot provide medical care
• I will not request transportation in emergency situations (call 911 instead)

5. Signature and Proof of Service

I agree to provide electronic signatures confirming pickup and drop-off for billing and compliance purposes. I understand these records may be shared with my insurance provider or broker.