Ride Eligibility & Registration Form

Ride Eligibility & Registration Form

Register for Transport Helpers ride services. Please complete all sections to determine eligibility and consent for participation.
SECTION 1 — RIDER INFORMATION
Application Full Name

First NameMiddle & Last Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Language

Other
SECTION 2 — EMERGENCY CONTACT
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 3 — TRANSPORTATION NEEDS
What type of transportation assistance do you require?

Other
SECTION 4 — MOBILITY INFORMATION
Do you use any mobility aids?

Other
SECTION 5 — TRAVEL SUPPORT
Do you travel with a caregiver or escort?
If yes, please provide caregiver name:

First NameLast Name
Caregiver's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 6 — PICKUP ASSISTANCE
Please let us know if you require assistance with:

Other
SECTION 7 — HEALTH & SAFETY NOTES (OPTIONAL)
To ensure safe transportation, please list any information drivers should be aware of:
For Example: Balance issues, Hearing impairment, Vision impairment, Oxygen tank, etc.
SECTION 8 — ADDITIONAL ENROLLED SERVICES
Please check any services, programs, or supports you currently receive or participate in:

Other
SECTION 9 — CONSENT & AUTHORIZATION
I certify that the information provided is accurate and understand that Transport Helpers LLC will use this information solely to provide transportation services.

I understand that my information may be shared with authorized transportation partners when necessary to coordinate services.
Applicant Signature
Date (Applicant Signature)

MonthDayYear
Date
SECTION 10 — FORM COMPLETED BY REPRESENTATIVE

(IF APPLICABLE)
Representative's Full Name

First NameMiddle & Last Name
Relationship to rider
Phone Number (Representative)
Please enter a valid phone number.Format: (000) 000-0000.
Signature (Representative)
Date (Representative Signature)

MonthDayYear
Date
SECTION 11 — PAYMENT INFORMATION
How will this transportation service be paid for?
Medicaid / Insurance Coverage

If your transportation is covered by Medicaid or another approved insurance program, please provide the following information:
Insurance Provider / Program Name:
Member ID Number:
Case Manager / Care Coordinator (if applicable):
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Staff Use Only – Eligibility Determination Notes
Private Pay
Private pay rides may be paid using one of the following methods:

Other
Promotional Code
If you have received a promotional ride credit or code, please enter it below:
Billing Contact (if different from rider)
Full Name

First NameMiddle & Last Name
Relationship to Rider
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should be Empty:

Ride Eligibility & Registration Form

SECTION 1 — RIDER INFORMATION

SECTION 2 — EMERGENCY CONTACT

SECTION 3 — TRANSPORTATION NEEDS

SECTION 4 — MOBILITY INFORMATION

SECTION 5 — TRAVEL SUPPORT

SECTION 6 — PICKUP ASSISTANCE

SECTION 7 — HEALTH & SAFETY NOTES (OPTIONAL)

SECTION 8 — ADDITIONAL ENROLLED SERVICES

SECTION 9 — CONSENT & AUTHORIZATION

SECTION 10 — FORM COMPLETED BY REPRESENTATIVE

SECTION 11 — PAYMENT INFORMATION

Medicaid / Insurance Coverage

Private Pay

Promotional Code

Billing Contact (if different from rider)