Schedule Private Pay Transportation | We Simply Care Transport

Submission of this form does not guarantee acceptance or availability. A team member will confirm eligibility and scheduling upon review.

How did you hear about We Simply Care Transport?

Service Type

Transportation Only
Transport & Escort/Accompany to appointment
Escort/ Accompany to appointment

We will send you a QuickBooks Invoice in which you will be able to pay with Credit or Debit Card. Just let the dispatcher know your preference. For Medicaid clients, please return to the Home page and use the Medicaid link to submit your trip request.

Date / Time of the Appointment:

Date

Time

Type of Appointment

Passenger Name

First

Last

Mobile Number (preferred)

By providing your mobile number, you will receive notifications regarding your upcoming trip directly from our schedule.

Phone Number

Email Address

By providing your email address, you will receive notifications regarding your upcoming trip directly from our schedule.

Level of Service

Ambulatory (Able to Walk / Uses a Walker)
Wheelchair (Max 30in wide)
Power/Electric Wheelchair (Max 30in wide)
Bariatric (Special Equipment Required)

Wheelchair Service Requirements (Read Before Submitting)

For wheelchair transport, the mobility device must be 30 inches wide or less. The combined weight of the rider plus the wheelchair/power chair must not exceed 850 lbs. If these limits are exceeded, WSCT may be unable to provide service with the dispatched vehicle, and the trip may be canceled or rescheduled.

Bariatric Transport Notice

Bariatric transportation requires advance review to ensure appropriate vehicle configuration, securement equipment, and staff availability. To determine our capacity to safely transport, the estimated weight of the individual must be provided. Failure to provide accurate information may result in trip delay, rescheduling, or cancellation.

Wheelchair Limits Acknowledgment

I confirm the wheelchair/power chair is 30″ wide or less and the combined rider + device weight does not exceed 850 lbs.irst Choice

Combined rider + mobility device weight (required for bariatric transport)

This information is used solely to determine vehicle and equipment suitability.

Bariatric Capacity Acknowledgment

I acknowledge that bariatric transport availability is based on accurate weight disclosure and is subject to WSCT vehicle and equipment capacity.

Wheelchair Rental (additional fee)

Yes
No

There is an additional fee for wheelchair rental of $25.00

Additional Passengers (additional fee will apply)

Trip Direction

One Way
Round Trip

Return Trip Type

Fixed Return Time
Call When Ready (CWR)

Scheduling Pattern

One-Time Trip
Recurring Trip (Standing Order)

Recurring & Round-Trip Policy Notice

Facility Scheduling Notice
Round-trip and recurring services require advance scheduling and resource allocation. Each scheduled occurrence is considered an individual trip. Changes or cancellations to any occurrence require at least 24 hours’ notice to avoid applicable fees. Late cancellations or no-shows for either leg of a round-trip may be billed in accordance with WSCT policy.

Round-trip and Recurring trip Acknowledgement

I acknowledge that round-trip and recurring trips are subject to WSCT’s cancellation and no-show policy,

Is this a dialysis or physical therapy trip?

Yes
No

Days of Service

Recurring Start Date

Limits trip dialysis

Recurring End Date (leave blank if ongoing)

Chair Time or PT Time (if provided by facility)

Expected length of your appointment

Long Distance Trip? (25 miles or more)

Yes
No

Pick Up Address (if applicable, include the name of facility)

Address Line 1

Address Line 2

City

State

Zip Code

Destination Address and Name of Facility

Address Line 1

Address Line 2

City

State

Zip Code

Cancellation Notification

Individual Private Pay
Facility / Organization Scheduled Private Pay

Facility Only Message

Facility Scheduling Notice
Facility-scheduled trips canceled within 24 hours, driver arrives for pickup, and the rider is not ready, or provided with incorrect information, may be billed at the full trip rate.

Individual Client Private Pay Notice:

Cancellation Policy (Private Pay)
Cancellations made with less than 24 hours’ notice may incur a fee.
Cancellations made within 2 hours of scheduled pickup or no-shows are non-refundable.

CANCELLATION ACKNOWLEDGEMENT

I acknowledge and agree to We Simply Care Transport & Services’ cancellation and no-show policy.

Comments:

Form Submission Verification

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