Transportation Request & Authorization Form

Transportation Request & Authorization Form

Complete your trip details, safety and vehicle authorization, and acknowledgements for SCCS approval.
Client Information & Eligibility
Client full name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Client ID or account number
Trip Request Details
Trip Type / Purpose

Other
Appointment / Provider or Destination Name
Pickup Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Requested Pickup Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested Pickup Time

Hour Minutes

AM/PM Option
Is This a Recurring Trip?
- Is an Additional Stop Needed?
- Emergency Contact & Responsible Party
- Who is completing this form?
  
  Other
- Emergency Contact Name
  
  First NameLast Name
- Relationship to Client
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary Contact Name and Relationship
- Responsible Party Signature
- Mobility, Safety & Medical Transportation Needs
- What mobility aids does the client use?
  
  Other
- Has the client had any falls in the last 90 days?
- Does the client use oxygen?
- What safety risks or precautions should transportation staff know about?
  
  Other
- Describe any safety risks, triggers, or precautions in detail
- List any other medical or transportation notes for review
- Are there any restrictions that may affect pickup, drop-off, or routing?
- Vehicle Authorization & Concerns
- Is the vehicle authorized for client transportation use?
- Vehicle year, make, and model
- Vehicle license plate number
- Are there any vehicle concerns to report?
- If yes, describe the concern(s) and any relevant details
- Acknowledgements, Review & Signature
- Acknowledgements
- Consent to Review and Verification
- Review Before Submitting
- Client Signature
- Client Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Transportation Request & Authorization Form

Client Information & Eligibility

Trip Request Details

Emergency Contact & Responsible Party

Mobility, Safety & Medical Transportation Needs

Vehicle Authorization & Concerns

Acknowledgements, Review & Signature