FAX TO RideCare: 952-967-5980 Facility Name:

Name:

Member #: Facility Phone #/Contact name:

Date of birth:

Best phone # to reach member:

Pick up address	Destination Name	Destination Address	Appointment Date	Appointment Time	Additional Riders? Name, if yes.	Pick up time	Mode of transportation (assisted, wheelchair, stretcher, etc)	RideCare Auth #

Driver/vehicle notes: Revised 9/21/2016