Medical Lodging, Medical Traveler, Medical Insurance

Encounter Form

Upon completion of all applicable information and after submission is complete, Hospital Traveler will send an email confirmation receipt to the address provided on the application.
Please note that all requests should be from a medical staff member of the facility providing the medical service and/or providing the lodging. Direct patient requests are not accepted. Once we validate a request, Hospital Traveler will begin the eligibility process.

We look forward to being of service,
Hospital Traveler Staff

Complete this Application Form

* Patient First Name
* Patient Last Name
* Patient DOB
* Patient Street Address
* Patient City
* Patient State
* Patient Zip
Home Telephone #
Work Phone
County
Medicaid #
Private Health Insurance (If Applicable)
Subscriber Identification #
Medical Center
Arrival Date
Anticipated Departure Date
* Submitter's Email Address
* Submitter's Name
* Contact Telephone #

* required fields

Your Feedback is Important

Thank you for visiting our website. Please fill out the following form to request information about our products and services or to provide feedback about our site. When you are finished, click the 'Submit' button to send us your message.

Patient Lodging and Travel

Reservations only: 866-889-9370

Medicaid and Insurance

Reservations and Information: 866-450-0060 or medicaid@hospitaltraveler.com