Medicaid Trip Reservation - We Simply Care Transport

Submission does not guarantee acceptance. Dispatch will confirm eligibility and availability.

This form is for Medicaid trip requests only.

Service Area Notice

WSCT currently provides Medicaid transportation within approved service areas. Trips outside coverage (including Chicago) may not be available. Dispatch will confirm eligibility.

RIDER / CONTACT INFO

Passenger Name

First

Last

IF YOU ARE COMPLETING THIS FORM ON BEHALF OF SOMEONE ELSE, ENTER PASSENGER INFO HERE. THERE WILL BE AN AREA BELOW WHERE WE WILL NEED YOUR NAME AND CONTACT INFO BELOW.

Passenger Cell Number

Email Address

Client Type

Individual (Medicaid Member)
Facility / Organization

Medicaid #:

Please enter your Medicaid number here:

Transdev RTN # (Authoriazation #)

If you do not have a RTN # please call TRANSDEV / NAPSPAP 1-877-725-0569 after WSCT confirms availability to transport.

Level of Service

Ambulatory (Able to Walk)
Wheelchair (30″ width MAX)

If you selected wheelchair, please specify the type of wheelchair (standard or bariatric). Our ramp is 30 inches wide. You will need to request a standard wheelchair for transport if you don’t have one.

Bariatric

Yes
No

Do we need to provide a wheelchair?

Yes
No

There is an additional fee for wheelchair rental of $25.00

Trip Direction

One-Way Trip
Round Trip

Date / Time

Date

Time

Type of Appointment

Expected length of your appointment

Additional Passengers

Long Distance Trip? (25 miles or more one-way)

Yes
No

Pick Up Address

Address Line 1

Address Line 2

City

State

Zip Code

Destination Address

Address Line 1

City

State

Zip Code

Person requesting on behalf of the client:

First

Last

Phone Numbers

Please include an office and cell # in order to receive update notifications regarding the trip you are scheduling for someone else.

appointment # Long

Email of person scheduling

Comments:

How did you hear about We Simply Care Transport?