RideConnect Transportation Ride Request Form

RideConnect Transportation Ride Request Form

Please note that if you do not receive an email acknowledgement after you hit the submit button - your submission did not go through. If you want a copy of the filled form, use the print feature.
Please read before filling out this form: If you are requesting this ride for more than one passenger, call South Country Health Alliance Member Services at 1-866-567-7242 for assistance.
Today's Date*
mm-dd-yyyy
Contact Name*

First NameLast Name
Contact Phone Number*

Area CodePhone Number
Contact Email*

Confirmation EmailThis email address is where you will receive your email acknowledgement of submission.
Who do we contact to confirm ride or if we need additional information if different from above?:
Alternate Contact Name

First NameLast Name
Alternate Contact Phone

Area CodePhone Number
Member Name*

First NameLast Name
Member ID Number*
Member Date of Birth*
mm-dd-yyyy
If the member being transported is 17 years old or younger and riding without a parent or guardian, the parent or guardian must complete the Minor Parental Authorization Form (pdf) prior to scheduling a ride.
Transfer Type*

Assisted TransportationUnassisted Transportation
Transportation Mode

Unassisted TransportWheelchair TransportStretcher Transport
Lift or Ramp Needed?

YesNo
Member Height
Member Weight*
*Required for Wheelchair and Stretcher Transport
Wheel Base of Wheelchair
Mobility Aids
(Example: Cane, Walker, Crutches)
Does this ride require additional passengers?*

YesNo
Name(s) of Other Passenger(s)
First and Last Names, Separate Each Individual by Comma
Date(s) of Birth of Other Passenger(s)
mm-dd-yyyy, Separate Each Individual by Comma
Car Seat Needed?

YesNo
Car Seat Notes
Service Animal Needed?*

YesNo
If Yes, Type of Service Animal
Same Day Request*

YesNo
Please know that we may not be able to schedule this ride due to the short notice (less than 72 hours/3 days). We will try our best but you may have to find your own ride or reschedule your appointment.
Round Trip or One Way*

Round TripOne Way
Appointment Date*
mm-dd-yyyy
Appointment Time*
HH:MM AM/PM
Length of Appointment*
What type of appointment is the member attending?*

MedicalDentalPharmacyChiropractorMental Health
Will the member be undergoing general anesthesia?*

YesNo
Members undergoing general anesthesia will likely have an additional passenger attending their appointment. If you have not selected "Yes" to additional passengers above, please do so and fill out names and dates of birth for any additional passengers before proceeding.
Requested Pick Up Time*
HH:MM AM/PM
Pick Up Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drop Off Location Name (Provider Name)*
Drop Off Location Phone Number*

Area CodePhone Number
Drop Off Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Comments to Dispatch
Other Notes
To save a copy of this form before you submit, click "Print Form" below.

This form will be sent securely to RideConnect at rideconnect@mnscha.org when you click "Submit." If you do not receive an email acknowledgement of your submission then your submission did not go through.

For questions, call South Country Health Alliance Member Services at 1-866-567-7242.
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