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  • 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.

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

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  • 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.

  • 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.


  • 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.

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  • 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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