RideConnect Transportation Ride Request Form

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 Name Last Name

Contact Phone Number *

Area Code Phone Number

Who do we contact to confirm ride or if we need additional information if different from above?:

Alternate Contact Name

First Name Last Name

Alternate Contact Phone

Area Code Phone Number

Member Name *

First Name Last 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 Transportation Unassisted Transportation

Transportation Mode

Unassisted Transport Wheelchair Transport Stretcher Transport

Lift or Ramp Needed?

Yes No

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? *

Yes No

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?

Yes No

Car Seat Notes

Service Animal Needed? *

Yes No

If Yes, Type of Service Animal

Same Day Request *

Yes No

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 Trip One Way

Appointment Date

Date

Appointment Date *

mm-dd-yyyy

Appointment Time *

HH:MM AM/PM

Length of Appointment *

What type of appointment is the member attending? *

Medical Dental Pharmacy Chiropractor Mental Health

Will the member be undergoing general anesthesia? *

Yes No

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

City State / Province

Postal / Zip Code

Drop Off Location Name (Provider Name) *

Drop Off Location Phone Number *

Area Code Phone Number

Drop Off Location Address *

Street Address

Street Address Line 2

City State / 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."

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