Welcome to the Transportation Wizard

This simple wizard will assist you with submitting your ride requests including fuel and bus passes. Requests must be for Medicaid qualified people and appointments and you must have used our services in the last 3 months.

Click Next to begin

If you do not receive a confirmation e-mail we might not have received your request. If you do not receive the confimation or a phone call from one of our call center representatives within 24 hours contact us via phone immediately!
All information is being passed via a secure web site and afforded protection exceeding HIPAA regulations!

Basic Information:

Select the date of your Trip:
Confirmation E-Mail Address is:
Yes if used our service in the last 3 months?:	Yes      No
Yes if mobility aids have not changed.:	Yes      No
Yes if your need for an attendant has not changed.:	Yes      No
Trip is:  One-Way  Two-Way (Round Trip)

Client Information:

What is the Client's First Name?
What is the Client's Middle Initial?
What is the Client's Last Name?
What is the Client's Date of Birth?
What is the Client's Phone Number?
What is your name?
Your relationship to client?

Transportation Details Pick-Up:

What is the Pick-Up Address?
What is the Pick-Up City?
What is the Pick-Up Zip Code?
What is the Appointment Time?
This request is for:   Ride    Fuel    Bus Pass  Other

Transportation Details Drop-Off:

What is the Appointment Address?
What is the Appointment City?
What is the Appointment Zip Code?
What is the Return Time? (time done with appointment)
What type of Appointment is this?	Primary Care Phys,Occ, Speech Therapy Dental Drug & Alcohol Mental Health OB-GYN Methadone Radiology Dialysis Specialty Laboratory Medical Equipment Podiatry Vision or Optical School

Appointment Information:

What is the Doctor or Dept. Name?
What is the Doctor or Dept. Phone Number?

Special Instructions:

Please specify any special transportation instructions for the driver or trip broker. For Fuel Reimbursement, Fuel Card, or Bus Pass please note below.

Send Data to the Server

We have now collected all of the necessary information and we are ready to send that information to our server for processing.

Click 'Send' when you are ready to send the information to the server.
Note: and remember if you do not receive a confirmation e-mail or call from one of our customer service representatives your request may not have gone through processing and you must call in your request.