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Contact Genex Medical Transportation
Practice Name/Organization
*
First name
*
Last name
*
Email
*
Phone
*
Preferred Contact Method
*
Email
Phone
Level of Transportation Needed (Please check all that apply)
*
Ambulatory/Minivan
Wheelchair Van
Bariatric Wheelchair
Stretcher
Practice/Organization Type
*
Estimated Monthly Rides Volume
*
Type or Select an Option
Payer Mix (Please check all that apply)
*
Medicare
Medicaid
Facility Pays
Rider Pays
Private Insurance
Current Transportation Methods
*
Additional Notes and Remarks
*
Submit
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