Apply for Free NEMT-Rides
Disclaimer: Free ride assistance is limited to one (1) complimentary ride per person, per month, subject to availability and eligibility verification. Proof of uninsured status and medical appointment may be required. Service areas and scheduling limitations may apply.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please enter Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please enter Appointment Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Please enter Appointment Date & Time
Optional Verification Upload: To help speed up the eligibility review process, applicants may voluntarily upload proof of uninsured status, medical appointment confirmations, or a valid photo ID. Please do not submit Social Security numbers, financial information, or proof of income documents.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please Leave a detailed Message
*
Submit
Should be Empty: