Ride2MD Reservation Form
Thank you for visiting the Ride2MD website. Our goal is to provide each and every passenger safe and timely transportation to and from your medical appointment as efficiently as possible.

We are grateful you have chosen Ride2MD to fulfill your medical transportation needs. Please take a few moments to complete the reservation form below. There are certain fields that are required in order to ensure we properly coordinate your transportation needs and are able to communicate with you during the transportation process. Once your transportation request is received, one of our Customer Service Specialists will coordinate transportation for you and contact you once your transportation is confirmed.

Our hours of operation are Monday - Friday, 7 am - 7 pm. All requests for transportation submitted outside of our hours of operation will not be processed until the next business day.

Email address *
Requestor Name *
Please enter your name if you are submitting a personal request for transportation. If you are a representative from one of our valued clients submitting a request for your patient, please enter the name of the company you represent.
Your answer
Requestor Phone Number
Your answer
What Company Do You Work For?
If you are entering a request for transportation for a patient of yours, please indicate the company you represent.
Appointment Date *
MM
/
DD
/
YYYY
Appointment Time *
Time
:
Return Time
Time
:
Level of Service *
The Level of service describes the type of assistance you may require when coordinating your transportation. Ambulatory or (AMB) indicates that you are able to move around freely without assistance. Stretcher (STR) indicates that you require a stretcher during transportation. Wheelchair or (WCH) indicates that you have a personal Wheelchair or motorized vehicle and require a specialized vehicle to coordinate your transportation. Should you require the services of an ambulance, we ask that you contact our on of our Customer Service Specialists at 855.631.7433 to better assist you.
Passenger First Name *
Your answer
Passenger Last Name *
Your answer
Pick-Up (P/U) Location (Description)
Where will we pick you up? Your home, place of work, hospital, etc.
Your answer
Passenger P/U Address *
Your answer
Passenger P/U Address 2
Your answer
Passenger P/U City *
Use the drop-down menu below to select the city where we will pick you up. If your city is not listed, please select the city that is closest to where we will pick you up.
Passenger P/U State *
Use the drop-down menu below to select the state that you reside in. If your city is not listed, please enter it in the miscellaneous notes section below.
Passenger P/U Zip Code *
Your answer
Mobile Phone *
Please take a moment to provide us with your mobile or cell phone number. The Customer Service Team will reach out to you during your transportation experience to give you updates regarding an ETA or driver information. If we do not have your mobile or cell phone number, it becomes very difficult to reach you to provide you with important updates. At Ride2MD, we will not share your personal information with anyone or contact you at anytime unless it is in regard to the transportation services we provide you!
Your answer
Other Phone
Your answer
Drop-Off Location (D/O) (Description)
Where will we drop you off? Are we taking you to your Primary Physician, hospital, dentist, therapist or another location? This helps us ensure we are taking you to the correct location or know how to reach you when you are ready to go home!
Your answer
D/O Address
Your answer
D/O Address 2
Your answer
D/O City *
Use the drop-down menu below to select the city that we are dropping you off. If your city is not listed, please select the city that closest represents where we are dropping you off.
D/O State *
D/O Zip Code *
Your answer
D/O Phone
Please provide the
Your answer
How are you paying for your transportation?
If your insurance is paying for your transportation, who is your insurance provider?
Do you have an Authorization Number?
Your answer
Passenger Date of Birth
MM
/
DD
/
YYYY
Member ID *
In the event that your insurance provider covers the cost of your transportation, please enter your medical insurance ID number. This number can be found on the members' insurance card. IF YOU DO NOT HAVE YOUR MEMBER ID, PLEASE ENTER N/A
Your answer
Member Effective Date
Please provide us with the date your medical insurance became effective. This date can be found on the members' insurance card.
MM
/
DD
/
YYYY
Travel Companion?
Does the passenger require any special assistance during transportation?
Your answer
Trip *
Same Day Trip *
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