Private Pay Ride Request Form

WellCare Support Inc 310 Mid Continent Plaza Suite 614 West Memphis, AR 72301 nemt@wellcaresupport.com 870-394-4681

Non-Emergency Medical Transportation (NEMT) Services

WellCare Support Inc. provides safe, dependable, and cost-effective shared transportation for individuals needing assistance traveling to and from medical appointments. As a shared ride service, you may be traveling with other passengers. To ensure a smooth experience for everyone, we ask that all riders remain courteous and respectful.

Drivers are not permitted to make unscheduled stops, detours, or trip modifications. To ensure timely service, please be ready at your scheduled pickup location and time, as delays can impact other scheduled trips. If you need to share additional information about your trip or require any medically necessary stops, please include those details in the comments section of this form.

Service Area & Distance Limits

We currently provide transportation services in Arkansas, Tennessee, and Georgia, with transportation available up to 200 miles one way. Transportation beyond this distance may require special approval and arrangements.

Our service areas are limited to the following counties:

Arkansas: Mississippi, Greene, Craighead, Poinsett, Cross, St. Francis, Crittenden, Lee
Tennessee: Shelby, Tipton, Fayette
Georgia: Rockdale, DeKalb, Clayton, Henry, Fayette, Fulton, Douglas, Cobb, Gwinnett

If your pickup address is outside these counties, we will not be able to provide service.

Will your trip exceed 200 miles one way?*

YesNo

Is your pickup address located within one of the counties listed above?*

YesNo

Passenger Name*

First NameLast Name

Passenger Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

Requested Pickup Date*

Date

Requested Pickup Time:*

Hour Minutes

AM/PM Option

Pickup & Destination Information

Pickup Location (Must be within service area):

Address*

Address

Street Address Line 2

CityStateZip

Destination (Medical Facility):

Name of Facility*

Address*

Address

Street Address Line 2

CityStateZip

Additional comments (if applicable):

Transportation Details: type of transportation needed*

Ambulatory (Standard) - Rider can walk unassistedWheelchair Accessible - Rider requires a wheelchair-accessible vehicleStretcher Transport - Rider is unable to sit upright during transport

Will you require assistance entering/exiting the vehicle?*

YesNo

Will someone be riding with you? (If yes, 1 additional passenger allowed)*

YesNo

For the safety of yourself and others, will you be comfortable wearing a mask during transport?*

YesNo

Important Information About Your Ride

All ride requests automatically include a return trip and will be charged as a round-trip fare, even if the return ride is not used.

Ride requests must be submitted at least 3 business days in advance to ensure availability.
Once your request is processed, you will receive a confirmation email with an invoice attached, detailing the itemized charges.
Payment is required to finalize your booking.

For assistance completing this form or any questions, please call us at (870) 394-4681 or email nemt@wellcaresupport.com.

Rider Tips for a Smooth Experience

Be Ready! - Drivers are on a schedule, so please be on time.
Be Respectful & Courteous - Share the ride comfortably with others.
Know Your Schedule - Keep track of your appointment time.
Contact Us for Changes - Call immediately for cancellations or reschedules.
Keep Our Number Handy - Have our contact info for quick assistance.

Acknowledgment & Signature

By submitting this request, I acknowledge that I have read and understand the policies outlined in this form. I understand that all ride requests automatically include a return trip and that I will be charged for the full round trip even if I do not use the return portion. I agree to be ready at the scheduled pickup time and location to avoid delays that may affect other passengers. I understand that WellCare Support Inc. operates a shared transportation service, and I will be respectful of other riders.

I confirm that the information provided in this form is accurate, and I agree to the terms and conditions of WellCare Support Inc.'s private pay transportation services.

Passenger Name Print*

Passenger Signature*

Date*

Date

Authorized Representative If applicable

Relationship with Passenger