VTS Provider Form

Provider Form for Ventura Transit System
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Job Position*
Name of Business*
National Provider Identifier (NPI) #*
Do you have a current Business License?*

YesNo
Does your business have liability insurance w/limits of $1,000,000.00 claims and 3,000,000.00 aggregate?*

YesNo
Is your business registered with Medi-Cal?*

YesNo
How many drivers does your business have?*
Select Service Area(s)*

Ventura CountyL.A CountySanta Barbara CountySan Luis Obispo CountyKern CountyOther
Do you provide Wheelchair transportation?*

YesNo
How many Wheelchair Assisted vehicles?*
Desired Rate for Pick-Up*
Desired Rate per Mile*
Desired Rate per Wait Time (30 minutes)*
Desired Rate per Attendant*
Do you provide Gurney transportation?*

YesNo
How many Gurney Assisted vehicles?*
Desired Rate for Pick-Up*
Desired Rate per Mile*
Desired Rate per Wait Time (30 minutes)*
Desired Rate per Attendant*
Do you provide Ambulatory transportation?*

YesNo
How many Ambulatory vehicles?*
Desired Rate for Pick-Up*
Desired Rate per Mile*
Desired Rate per Wait Time (30 minutes)*
Desired Rate per Attendant*
Anything else you would like us to know?
Should be Empty:

Provider Form for Ventura Transit System