RydeAide Request Form

RydeAide Request Form (Family/Facility)

Book a RydeAide Companion

Section 1: Scheduler Contact Information
Scheduler's Name:*
Relationship/Role*
Facility Name: (N/A if not a facility)*
Scheduler's Email:*
example@example.com
Scheduler's Phone Number:*
Please enter a valid phone number.

Section 2: Appointment Details
Rider's Name*

First NameLast Name
Appointment Date*

MonthDayYear
Appointment Time*

Hour Minutes

AM/PM Option
Estimated Length of Appointment*
Pickup Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobility Type*
Transportation Method

Section 3: Special Needs (No PHI)
Special Needs*

Dementia/Memory or Cognitive SupportNon-Verbal or Limited CommunicationVision ImpairedHearing ImpairedOther (*Explain below)None
Special Needs Notes: (Important information and/or instructions)*

Section 4: HIPPA Authorization
HIPAA Authorization for Escort Services

I authorize RydeAide, LLC and the assigned RydeAide companion Aide to access, use, and share the Rider's health information only as needed to accompany the Rider to and from medical appointments or related outings.

Scope of Authorization
- The Aide may be present during the medical appointments.
- The Aide may communicate with healthcare providers only for the purpose of confirming appointment details, assisting with instructions, and supporting safe participation in the appointment.
- Only the minimum necessary information will be accessed or shared.
Expiration
- This authorization remains valid until I revoke it in writing.
- I understand I may withdraw my consent at any time by notifying RydeAide in writing.
My Rights
- I understand this authorization is voluntary.
  Refusing to sign will not affect my ability to receive other services from RydeAide.
- I understand that once information is disclosed to the Aide, it may not be protected by HIPAA if shared outside the scope of this authorization.
I understand and agree.*

Yes,

Section 5: Consent and Acknowledgment
By signing below, I acknowledge and agree that:
- The information I have provided in this form is accurate to the best of my knowledge.
- I give permission for RydeAide, LLC to use this information to schedule services with a Rydeaide companion Aide and to contact me (by phone, email, or text) regarding the appointments.
- I understand that submitting this form does not guarantee availability and that RydeAide will confirm appointment details with me.
- I understand that RydeAide does not provide transportation. The Aide will meet me at my home or designated location and accompany the Rider to and from my appointment.
Signature*

Clear
Date*

MonthDayYear
Application Status

New
Should be Empty: