Ride Request Form

RideConnect Request Form

Step 1 of 6 - Ride Request Contact Info

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Screening/Eligibility

South Country members may be eligible for transportation through South Country's RideConnect program. The questions below will be used to help determine member eligibility.

Does the member have coverage under MinnesotaCare?(Required)

Yes

Is the member under age 19, or a pregnant individual?(Required)

Yes

The member's coverage does not include transportation benefits.

Stop here.

Does the member have access to a vehicle that could be used for this ride? (i.e. their own vehicle, a family/friend who could drive them)(Required)

Yes

Please contact the member's county human services office for mileage reimbursement options.

Stop here.

Does the member reside in, or is being discharged to, a skilled nursing facility?(Required)

Yes

Does the member require stretcher transportation?

Yes

Rides for members that reside in a skilled nursing facility can be scheduled directly with a transportation provider, and do not need to go through RideConnect.

Stop here.

Is this for a same day or next business day ride?(Required)

Yes

RideConnect is not currently accepting same day or next business day rides. If there is urgency to this ride, where you feel RideConnect should make an exception, the requestor must call South Country’s RideConnect at 1-866-567-7242.

Stop here.

Please provide the member's name, South Country ID number, and date of birth.

First and Last Name of Member(Required)

First Last

South Country Member ID Number(Required)

Number from the South Country ID card that starts with a G and ends in 01

Member Date of Birth(Required)

If a member is 17 years old or younger and riding without a parent or guardian, a completed Minor Parental Authorization Form MUST be on file prior to scheduling any rides. Submitted rides will not be scheduled if there is not a valid form on file.

Contact Information

Contact information will be used by RideConnect to outreach with questions or issues, and to confirm that the ride has been scheduled. If someone besides yourself, like the member, should be contacted please be sure to list them. Only individuals listed in this section will be contacted.

Today's Date(Required)

Contact First Name(Required)

First

Contact Last Name(Required)

Last

Contact Phone Number(Required)

Contact Email

Contact 1 Relationship to member(Required)

Alternate Contact First Name

First

Alternate Contact Last Name

Last

Alternate Contact Phone

Alternate Contact Relationship to member

Mode of Transportation

Does the member require unassisted or assisted transportation?(Required)

Unassisted

Assisted

Does the member need ambulatory, wheelchair assistance, or stretcher transport?(Required)

Ambulatory Assistance

Wheelchair Assistance

Stretcher Transport

Member Approx. Weight in pounds*

*Required for Wheelchair and Stretcher Transport

What type of wheelchair is used?

Manual

Powered

What is the width of the wheelchair?

Standard

Oversized

Please check all the mobility aids used.

Cane

Crutches

Scooter

Walker

Service Animal

What type of scooter?

Knee

Motorized

Describe service animal

Is a lift or ramp vehicle needed?

Yes

Appointment Information

What type of appointment is the member attending?

Medical

Dental

Mental Health/Behavioral Health

Pharmacy

Dialysis

Appointment Date(Required)

Appointment Time(Required)

Hours

Minutes

AM/PM

Length of Appointment(Required)

Requested Pick Up Time

Hours

Minutes

AM/PM

Pick Up Time (Added Info)

Pick up time is firm

Pick up time is flexible

Leave pick up time to provider

What type of ride are you requesting?

Pick Up Location Address(Required)

Street Address Address Line 2 City State ZIP Code

Drop Off Location Name(Required)

Provider's office name

Drop Off Location Phone Number(Required)

Provider's office phone number

Drop Off Location Address(Required)

Street Address Address Line 2 City State ZIP Code

Provider's address

Notes to transport provider

Is this a recurring ride request?

Yes

Do all the details about the ride remain the same?

Yes

For example: the same time and place following a pattern (daily, MWF, or every Thursday.)

RideConnect can schedule 30 days out, except for dialysis rides.

A separate ride request form will need to be completed with those ride details. Only one ride request my be entered per form.

Describe how long you need the recurring ride. For example: Daily for the next 3 weeks, every Thursday in March, etc.

Is this a multi-leg ride?

Yes

A multi-leg ride is a ride with multiple stops on the same date.

Please enter the start time of each appointment, length of appointment, provider name, and provider address.

Start time

Length of appt

Provider name

Provider address

Click on the "+" symbol to add each additional stop's information.

Will the member be undergoing general anesthesia?

Yes

Member must have an accompanying passenger for this ride to be scheduled.

Will there be any additional passengers for this ride?

Yes

Please list the name and age of each passenger.

Name

Age

Click the "+" sign to add each additional passenger's information.

Will you be bringing any car seats?

Yes

For accuracy, please review all information entered for this ride request in the summary area. RideConnect will enter the request as received. It is your responsibility to ensure that all details are accurate so that the member receives the correct transportation services. If the information you have entered is correct, click Next.

You must agree to the HIPAA FORMS Service Privacy Statement before you can submit. Click on the link if you wish to read the privacy statement. Once you have checked the box, click “Submit” to securely send the request to RideConnect. You will not receive an email confirmation of your submission. When successful, you will see "Thank you, your form has been encrypted to protect your privacy and submitted successfully!" on the page. If you do not see this message, you may need to reenter your request. Hit the Previous button to see if your data is still in the form. Submission of ride request does not guarantee that there will be provider availability for the requested ride. All attempts will be made to schedule this ride. RideConnect will outreach to the contact person, from section 2, for notification on any ride issues or confirmation that the ride has been scheduled. For questions, call South Country Health Alliance Member Services at 1-866-567-7242. If you wish to enter a new ride request immediately, click your refresh button to be taken back to the start of the form.

RideConnect Request Form

Screening/Eligibility

Contact Information

Mode of Transportation

Appointment Information

Summary