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Begin Your New Journey Today

Salute 1st Signup Form

PARENT / GUARDIAN INFORMATION

First name

Last name

Email

Phone

Address

Country/Region

Address

City

Zip / Postal code

CHILD / CHILDREN'S INFORMATION

Child's Name

Age

Date of Birth

Insurance Provider / Billing Number

Gender ( Child 1)

How would you like your child to receive services (1)?

Virtual

In- Person

Child's Name(2)

Age(2)

Date of Birth (Child 2)

Insurance Provider / Billing Number(2)

Gender(2)

How would you like your child to receive services (2)?

Virtual

In- Person

Child's Name(3)

Age(3)

Date of Birth(3)

(3)Insurance Provider / Billing Number

(3)Gender

(3)How would you like your child to receive services?

Virtual

In- Person

Child 1 - Front of Medicaid Card Upload (if accessible)

Child 1 - Back of Medicaid Card Upload (if accessible)

Front of Medicaid Card Upload CHILD 2 (if accessible)

Back of Medicaid Card Upload CHILD 2 (if accessible)

Child 3 - Front of Medicaid Card Upload (if accessible)

Child 3 - Back of Medicaid Card Upload CHILD (if accessible)

I confirm that the applicant is an Ohio resident.

Our transportation service is FREE to Medicaid beneficiaries.

Health Services and Pharmacy rides to and from Destinations for, but Not Limited to the Following:

. Case Management Visits
. Chemotherapy
. Counseling Services
. Dialysis
. Diagnostic Assessments
. Doctor visits
. Hospital Discharge
. Medication Management
. Mental Health Services
. Pharmacy Prescription Pick-ups
. Physical Therapy
. Rehabilitation & Recovery
. Substance Abuse Services
. Therapy Sessions
. Transferring of Hospital Facilities

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FREE Non-Emergency Medical Transportation through Primary Care Solutions is an important service for individuals needing assistance getting to and from health-related appointments and pharmaceutical pick-ups. Medicaid beneficiaries provide NO out of pocket costs for any of the transportation services rendered.

Primary Care Solutions NEMT is a great choice when you really need someone to take you to appointments when the need is not immediately life threatening. The next time that you need to take a trip, consider non-emergency medical transportation.

You can make this call directly or have your caseworker, caregiver, doctor’s office, therapist, a friend or relative call the number listed and ask to be transported by Primary Care Solutions. It’s that simple. Just be ready and on time for pickup for a safe, professional and efficient transport to and from your destination.

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