Medicaid Trip Reservation

Medicaid Transportation Request

This form is for Medicaid/Medicare trip requests only. Submission does not guarantee acceptance. Dispatch will confirm eligibility and availability.

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
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.
Client Type
Please enter your Medicaid number here:
If you do not have a RTN # please call TRANSDEV / NAPSPAP 1-877-725-0569 after WSCT confirms availability to transport.
Level of Service
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
Do we need to provide a wheelchair?
There is an additional fee for wheelchair rental of $25.00
Trip Direction
Date / Time
Long Distance Trip? (25 miles or more one-way)
Pick Up Address
Destination Address
Person requesting on behalf of the client:
Please include an office and cell # in order to receive update notifications regarding the trip you are scheduling for someone else.