Colorado Facility Network

ColoradoFacility Network

Downloads

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 TitleDescription
Bariatric AssessmentA form to assess BMI to determine if a rider requires bariatric transportation.
Closest Provider CertificationRequired for all clients traveling more than 12 miles ambulatory or 50 miles in a wheelchair.
Consent and Release of LiabilityRequired by any parent or guardian if they are requesting their minor child (under the age of 18) be transported without their parent or guardian with them.
Gas ReimbursementForm used by a rider who has a friend or family member requesting mileage reimbursement for transporting the rider to a medical appointment.
Gas Reimbursement GuidelinesGuidelines for using the mileage reimbursement program.
Gas Reimbursement Payment SchedulePayment schedule for mileage reimbursement showing when claims should be received and the check disbursement date.
Level of Service CertificationRequired for all clients traveling by wheelchair or stretcher.
Mass Transit RiderRequired for clients medically unable to ride public transportation.
Standing Order-DialysisA form used by facility staff to request recurring transportation for a rider going to the same facility at the same time at least three times per week.
Trip OrderA form used by facility staff to request transportation for a rider who has a stand-alone medical appointment.

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