Sumexus

*Requestor Name

*Patient Name

*Relationship to patient

*Email

*Phone Numer

*Mailing Address 1

Mailing Address 2

*Mailing City

*Mailing State

*Mailing Zip Code

*Type of transport

*If wheelchair-bound, does the patient have their own wheelchair

*If the patient requires oxygen, do they have their own tank?

*What date and time is transport needed?

*Starting Address

Starting Address 2

*Starting City

*Starting State

*Starting Zip Code

*Ending Address

Ending Address 2

*Ending City

*Ending State

*Ending Zip Code

Additional needs

Special instructions/considerations

Online Payment
Pay with debit card, credit card and other convenient methods of payment. Once your are scheduled, you will receive an invoice to be paid before pickup.
Medicaid
Pay with Medicaid. Our representatives will walk you through the process.
Private pay
We will also accept other payment method such as upfront cash, Zelle and Venmo.