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Perry County JFS Non-Emergency Medical Transportation Request Form

Date of Request:

First Name:Client Being Transported

Last Name:Client Being Transported

Requester’s Name:

Agency/Phone #:

Case # if Known:

Social Security #:

Client Address/
Address to be
Picked Up at

Attendant/Children

Client Phone #:

Wheelchair/Walker?

Appointments
Date	Arrival Time	Length of Visit	Physician/Facility	Appointment Address(Please specify location. Example: Children's Hospital has several locations. Which one?)

Notes:

Return form to Perry JFS

Email: perryss@jfs.ohio.gov

Fax: 740-342-5491

or In-Person at: 5250 State Route 37 E, New Lexington, Ohio 43764

Protective ServicesChild SupportPublic AssistanceWorkforce

Amy L. Frame, Director5250 State Route 37 East • New Lexington, OH 43764 • Phone:(740) 342-3551 • Fax:(740) 342-5491 • jfs.perrycountyohio.gov