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Superior
Cornerstone
Home Care
Hospice

Superior
Cornerstone
Home Care
Hospice

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Mount Carmel Home Network
Columbus Connection

Superior Ambulance Service

Superior Ambulance Service makes medical transportation available to both ambulatory and non-ambulatory patients throughout Franklin County. The outstanding staff at Superior Ambulance Service is well trained and can transport patients to any local hospital or medical facility.

Use the form below to set up transportation:

MCE On-Site Coordinator 614-301-7811
MCG On-Site Coordinator 614-512-0109
MCSA On-Site Coordinator 614-403-9917
After hours Tel: 614-871-3210
Fax: 614-871-3251

CMN (Medicaid only)
W/C CMN
PCS

Referral Location

Referring Physician

Patient First Name

Patient Last Name

Patient Birthdate

Next of Kin

Patient Weight

Medical Necessity for Ambulance Transport ( Section 2 – Medical Necessity Information on the PCS )

Equipment (Hold [Ctrl] to select multiples)

Transportation type

Wheelchair (A representative from the wheelchair company will reach out to the patient in regards to payment for transportation)

Lyft – Charity

Ambulance

COVID-19 Status

Positive

Negative

Pending (Must Call with Results)

No Concerns (Not Tested)

Hospital to Hospital Reason - Mount Carmel Transfer Center USE ONLY!

Patient Request

Higher Level of Care (Service not available at sending hospital)

Continuity of Care

Psychiatric Facility

Patient pickup Location

Patient pickup date and time

Patient pickup will call

# of Steps

Patient destination: Name of facility & address (i.e. Winchester Care and Rehab, 36 Lehman Dr)

Accepting Facility Status

New Admit

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Primary Insurance (i.e. Ohio Medicare, Aetna Medicare, Anthem Medicare, Humana Medicare)