Provider Form for Ventura Transit System
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Job Position
*
Name of Business
*
National Provider Identifier (NPI) #
*
Do you have a current Business License?
*
Yes
No
Does your business have liability insurance w/limits of $1,000,000.00 claims and 3,000,000.00 aggregate?
*
Yes
No
Is your business registered with Medi-Cal?
*
Yes
No
How many drivers does your business have?
*
Select Service Area(s)
*
Ventura County
L.A County
Santa Barbara County
San Luis Obispo County
Kern County
Other
Do you provide Wheelchair transportation?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
Submit
Should be Empty: