To all Medicaid Bus Pass Clients:

You will need to fill out this form each month to determine if you have enough appointments to receive a bus pass.

Client's Name: 
Address: 
How many times a month will you use your pass? 
Which month are you requesting a pass for? 
Medicaid Number? 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 

You will need to complete this form completely including phone numbers and dates. We verify appointments before we issue any bus passes. If you are using the pass for AA and/or NA you will need to send in a copy of your sign in sheet. If you need more room please use the back of this page. You may print out a Word document or Adobe PDF document and return by mail to:

GPTMS
13825 Icot Blvd #613
Clearwater, FL 33760