Reproductive Care Ride Request

Free Ride Request Form

Please complete this form to request a ride to a reproductive care appointment. ACC facilitates and fund rides using several providers; based on the information you provide, we will match you with the best fit provider and then help make ride arrangements. We may follow up with additional questions as we work to get your ride set up.
Name*

First NameLast Name
Email
example@example.com
What's your preference for communication?

Phone callTextEmailWhat's AppOther
Phone Number*
Please enter a valid phone number.
Will you be over the age of 19 at the time of this appointment?
We do provide rides for minors, but we have special consideration around booking.
Please Select Appointment Type*
Reproductive care related appointments include prenatal and postpartum doctor’s appointments, appointments related to gender affirming care, routine OB-gyn appointments, dentist appointments for pregnant people, appointments for pelvic floor therapy, mental health appointments, newborn pediatric appointments, appointments relating to Medicaid or WIC, STI screenings, support groups related to reproductive care and MORE. If you think it relates to reproductive care but it’s not listed here, complete the form and let us know. At this time, ACC does not cover rides to personal residences, day care, work, grocery stores or other retail, schools, or sporting events.
Appointment Date*

MonthDayYear
We are best able to accommodate rides if we have 48 hours notice, however, we will do our best to find a driver with at least two hours notice for appointments that are between 10AM and 5PM on weekdays. Rides are always subject to the availability of drivers.
Pick Up Time*

Hour Minutes

AM/PM Option
Appointment Time*

Hour Minutes

AM/PM Option
Return Time

Hour Minutes

AM/PM Option
Please check all that apply:

This is a one way trip.I'm not sure what time I need a return.Other
Pick Up Address*

Street Address

Street Address Line 2

CityState

Zip Code
Appointment Address*

Street Address

Street Address Line 2

CityState

Zip Code
Return Address (if different than pick up address)

Street Address

Street Address Line 2

CityState

Zip Code
Number of passengers including you*
Another adult can ride with you to your appointment. We'll do our best to accommodate requests to have a child ride with you. We are not currently able to provide car seats or booster seats. If you are requesting a ride for someone under 16 to ride alone, please email lindsey@alabamacohosh.org. These rides typically require more time to book; please contact us at least five days in advance to ensure we can make these arrangements.
Ride Preference

We will do our best to book according to your preference. Some people prefer Lyft because they're more familiar with it and it gives the option for your return ride to be more flexible. Medical concierge transportation has drivers and vehicles that are specifically trained for medical transportation. If your insurance covers a ride, it will typically cover through medical concierge transportation. Medicaid and other rides do cover costs for prenatal appointments. If you have Medicaid, then we typically cover the cost of your first ride and then for subsequent rides we'll walk you through the process of booking a ride that Medicaid will pay for. We know that working with Medicaid and insurance can sometimes be overwhelming and exhausting. If it feels like that's just too much for you right now, then please let us know that. We would rather pay to get you to your appointments then for you to miss out on the care you need.
Do you have a preference on using Lyft vs a medical concierge service?

I prefer Lyft.I prefer a medical concierge.I need assistance getting into a vehicle and require a medical concierge.I don't have a preference.Other
Do you have medical insurance?*
Medicaid and many insurances cover transportation to doctor's appointments. If you have more than one appointment and need transportation regularly, we will see if we can help set up for your insurance to cover the cost of your rides.
I agree to the terms of ACC's Transportation Waiver and Assumption of Risk Agreement.*

Powered by Jotform Sign Clear

Free Ride Request Form

Ride Preference

Demographic Information