• Medicaid Non-Emergency Medical Transportation Request Form

    Request non-emergency medical transportation for a Medicaid-related medical appointment or care visit. Provide rider, trip, appointment, and assistance details so the transportation request can be scheduled correctly.

  • Rider Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Pickup and Drop-off Details

  • Need a return trip?*

  • Appointment and Trip Information

  • Medical Appointment Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Medical Appointment Time*
  • Requested Pickup Time*
  • Requested Return Pickup Time
  • Trip Type*

  • Mobility and Assistance Needs

  • Mobility Status*
  • Escort or Caregiver Needed*
  • Vehicle Accessibility Needs
  • Door-to-Door Assistance Needed

  • Request Review and Acknowledgment

  • Acknowledgment*
  • Should be Empty:
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