Consent and Liability Release

  • (Children under the age of 13 require specific approval by the Department of Health Care Policy and Financing)
  • I, do hereby affirm and attest that I am the legal guardian of the above stated minor child. This child is eligible to the best of my knowledge to receive Health First Colorado funded services, including transportation under the Non-Emergency Medical Transportation (NEMT) program operated by Veyo under a contract with the State of Colorado. I hereby authorize Veyo to arrange and/or provide transportation for this child without the need for an adult escort. By authorizing Veyo to arrange and/or provide transportation, I hereby release and indemnify Veyo and its employees, officers, agents, parent company, and affiliates: Veyo's contracted transportation providers and their employees, officers, agents, parent companies, and affiliates; and the State of Colorado and its employees, officers, agents, and agencies from any and all liability, causes of action, or claims of any nature whatsoever arising from or in connection with the transportation provided to the above named minor child by Veyo and its transportation providers.
  • Date Format: MM slash DD slash YYYY
  • **Please allow 2 business days' notice for scheduling. Individual trips can be submitted by calling Customer Service at 855-264-6368 prior to the start date requested.**

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