Inspire (SNBC) RideCare and Special Transportation Exception Request

To be completed by a health care provider or HealthPartners Inspire care coordinator.

Please reference the HealthPartners RideCare & Special Transportation Exception Request policy.

Fax “Attn: RideCare” @ 952 967-5980

Member & Requestor Information	Date of Request:
Member Name:
Member ID:	DOB:
Requester Name, Title & Entity:	Requester’s Phone:
Requester’s Email or fax:
Name & address of destination for request:	Appt date and time:
Request details
Please briefly describe the member’s health condition(s) that support request for exception to transportation benefit: Please list other clinics tried and failed: Type of Specialty requested: Mode of Transportation Needed: Prior Authorization Needed: (i.e. Mayo Clinic requires prior authorization therefore RideCare requires an Auth in place prior to scheduling transportation)
Additional Comments: