Professional Documents
Culture Documents
DATE OF APPOINTMENT:_________________________TIME:_______________
TO:
BEGINNING ODOMETER:_______________________ ENDING ODOMETER:________________________
(READING WHEN YOU LEAVE HOME OF CLIENT) (READING WHEN DROPPING CLIENT AT MEDICAL FACILITY)
FROM:
BEGINNING ODOMETER:_______________________ ENDING ODOMETER:________________________
(READING WHEN LEAVING MEDICAL FACILITY) (READING WHEN DROPPING CLIENT AT HOME)
I certify that my family has no other means of transportation available and the information above is accurate. Also, I agree to notify Waldo County Transportation of any
changes in my family’s MaineCare status, income, or transportation needs. I also authorize the above medical provider to verify that I kept the above appointment when
requested by the Waldo County Transportation Program.
A. Call 338-5757 and leave your appointment information on our message machine prior to going to your
appointment. Be specific and make sure to leave a phone number where you can be reached.
B. Have appointment verified by medical provider in the box in the upper right hand column. Attach appointment
card also.
H. Fill in the address of the person with the appointment including town.
L. Fill in the odometer readings, beginning and ending, for each one way trip.
M. Attach receipts for tolls, ferries etc, and fill in the blanks.