iCircle Care Transportation Form

Member ID
Member ID number can be found on your iCircle Member Card
Member DOB*

MonthDayYear
MM-DD-YYYY
Member Name*

First NameLast Name
Requester Name (if not a Member)*

First NameLast Name
Requester Email*
example@example.com
Requester phone number? *
### - ### - ####
What is the date of the appointment?*

MonthDayYear
MM-DD-YYYY
What is the time of the appointment?*

:HourMinutesAM/PM Option
**Please note, the pick-up time will be 1 hour prior to the appointment time unless additional travel time is needed.
Do you need more than 1 hour to travel to your appointment? If so, please how much time will you/the member need?
Where will you/the member be picked up for the appointment?
Enter your house number, street name, city, state and zip
Where will you/the member be picked up for the appointment?*
Are there any special instructions for the pick-up address?
What phone number can you/the member be reached at regarding this appointment? *
### - ### - ####
What is the name of the facility you/the member are traveling to?*
Facility Phone Number *
### - ### - ####
What is the street address of the appointment?
Enter the address number, street name, city, state and zip
What is the street address of the appointment?*
What type of medical appointment is the transportation for?*

Primary Care DoctorSpecialistSurgery inpatientSurgery outpatientPost operation appt
Will you/the member be calling the provider for the return ride home from the appointment?*

YesNo
What time will you/the member need to be picked up for the return trip home?*

:HourMinutesAM/PM Option
What type of vehicle is needed for transport?*
Preferred transportation provider?*

I have no preference
Secondary preferred transportation provider?
Name your secondary preference
Will you/the member need assistance from your home to the vehicle?*

YesNo
How many steps are at the home?*
If none enter 0
Will you/the member be bringing an assistive device for transport?*
Will you/the member need a wheelchair to be provided?*

YesNo
Will you/the member need a wheelchair for the duration of the appointment?*

YesNo
Will you/the member be traveling with an additional rider for assistance?*

YesNo
Will you/the member be traveling with portable oxygen?*

YesNo
If you/the member are traveling with oxygen, what is the amount (in liters)?*
Additional information/instructions
Who should the confirmation to be sent to?*
example@example.com
Should be Empty: