Request Transportation | Safety First Transportation

For a medical emergency, call 911. This form is for non-emergency transportation only and is not monitored for urgent medical needs.

Privacy note: please share only the information needed to coordinate the trip. Do not include diagnoses, medical records or Social Security numbers — details involving protected health information are handled through secure channels after our team contacts you.

Step 1 of 5 — Requester

Who is making this request?

I'm the patient Family member Caregiver Facility / case manager

Your name

Please enter your name.

Organization or facility (if applicable)

Relationship to patient

Phone

Please enter a phone number.

Preferred contact method

Best time to contact

It's okay to leave a voicemail

About the passenger

We only collect what's needed to coordinate the trip safely.

Patient name

Please enter the patient's name.

Patient phone (if different)

Date of birth (only if required by the payer or facility)

Emergency contact name & phone

Communication needs (hearing, vision, language, memory support)

Mobility type

Walks independently Uses a cane Uses a walker Manual wheelchair Power wheelchair Other describe below

Can the patient transfer to a vehicle seat independently?

Does the patient require an escort or companion?

Approximate passenger weight (only for safe equipment planning)

Mobility-equipment type & dimensions (if known)

Special accessibility instructions

Trip details Trip type

One-way Round-trip Recurring ride we'll set the schedule with you

This is a hospital discharge

This is a facility-to-facility trip

Pickup address

Please enter the pickup address.

Apartment, unit or room

Pickup contact (name/phone at pickup, if different)

Destination name

Please enter the destination name.

Destination address

Please enter the destination address.

Appointment date

Please choose a date.

Appointment time

Please choose a time.

Requested pickup time (if you have a preference)

Expected appointment duration

Return pickup

Number of stairs at pickup/destination

Elevator available?

Number of companions riding along

Additional stops (e.g., pharmacy connected to this trip)

Entry & vehicle-access notes

Payment & coverage How do you expect this trip to be paid?

Private pay Facility account Insurance / managed-care authorization Medicaid transportation authorization if accepted — to be verified Other Unsure — please contact me

Insurance company or plan

Authorization number (if already issued)

Case-manager contact

Please do not enter full member ID numbers here — our team collects any remaining details through a secure channel.

Billing contact

Purchase order / facility reference

Coverage is not guaranteed. Transportation is subject to eligibility, authorization, service availability and confirmation. Contact your insurance plan directly to understand your transportation benefits.

Review your request

Check the details below — use Back to correct anything.

I consent to be contacted about this request by phone or email.

Text me updates about this trip. Message/data rates may apply; reply STOP to opt out. (SMS policy)

I have read the Transportation Request Terms, Cancellation Policy and Privacy Notice.

I understand this is non-emergency transportation and that a submitted request is not confirmed until reviewed and approved.

Electronic signature (type your full name)

Please type your full name as a signature.

After submission you'll see confirmation that your request was received but not yet confirmed, and our team will contact you. An internal request ID is generated for tracking.