DD MedTrans Partner Provider Application
Basic Information
Business Name
*
Company Legal Name
*
Company DBA
Contact Name
*
Principal Owner Name
*
Phone Number
*
Fax Number
*
Email
*
Payment Methods Accepted
*
Credit Card
Check/Invoice
PayPal
Documentation
W-9
*
Insurance Documentation
*
Business License
Insurance Limits
Combined Single Limit
$
.00
Bodily Injury (Per Person)
$
.00
Bodily Injury (Per Accident)
$
.00
Property Damage
$
.00
Primary Dispatch Location
Location Address 1
*
Location Address 2
City
*
State
*
Zip Code
*
Transportation Services
*
Air Ambulance
Ambulatory - Standard car
Ambulatory - Large car
Ambulatory - SUV
Ambulatory - Van
Basic/Advanced Life Support & Stretcher
Stretcher - Bariatric
Basic/Advanced Life Support & Stretcher - Bariatric
Wheel Chair - Bariatric
Wheel Chair
Long Distance
Translation
Submit Application
