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Transportation Assistance Request Form

For urgent requests, please contact the UPHP Transportation Department at 1-800-835-2556
- Only one reimbursement form can be submitted per provider, per location.
- All reimbursement forms for mileage will be sent to the member, including buses and cabs.
- If you are requesting a ride from a volunteer driver, the reimbursement form will be sent to the volunteer driver.

Please select which request you want to submit:  

Who is making the request?

Member Info
Member Last Name:
Member First Name:
Member ID:
Member Date of Birth:
Home or Cell Phone Number:
Physical (Home) Address
Physical Street Address:
Physical City:
Physical State:
Physical Zip Code:



Mailing Address
Mailing Street or PO Box:
Mailing City:
Mailing State:
Mailing Zip Code:


Member Profile Assessment


Appointment Info
Type of Visit:
Provider Last Name:
Provider First Name:
Provider Phone Number:
Appointment Location Address:
Appointment City:
Appointment State:
Appointment Zip Code:
Appointment Dates (add up to 7 dates)


Please submit a separate request form for each provider and visit type.

Page Last Updated: 2/28/2017