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FH-CL-006 • VERSION 1.0
Transportation & Outing Authorization
Authorized destinations, vehicles, limits, charges and safety rules.
Digital workflow:
Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.
1. Record identification
Client name *
Date *
Completed by *
2. Authorization
Transportation authorized? *
Choose…
Yes
No
Effective date
Destinations / outing types
Vehicle source
Employee vehicle
Client / family vehicle
Rideshare / public transit
Driver license, insurance and vehicle verified
Choose…
Yes
No
Not applicable
3. Limits & safety
Mileage, parking, tolls and other charges
Routine destinations / restrictions
Mobility device / assistance review
Authorized errands and unscheduled-stop method
Accident / breakdown and emergency instructions
Scope limits reviewed *
No lifting
No transfers
No toileting
No personal care
4. Certification / acknowledgment
Electronic signature / typed name *
Signature date *
Notes
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