Ride Request Form

Ride Request 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?*

YesNo
Is the member under age 19, or a pregnant individual?*

YesNo
Member is not eligible for RideConnect services.

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)*

YesNo
Stop here.

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

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

YesNo
Does the member require stretcher transportation?

YesNo
Stop here.

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.

Is this for a same day or next business day ride?*

YesNo
Stop Here.

RideConnect is not currently accepting same day or next business day requests. A request submitted on Friday for a Monday ride is considered a next business day request. Holidays and weekend days do not count as business days. If there is urgency to this ride, where you feel RideConnect should make an exception, you must call South Country’s RideConnect at 1-866-567-7242.
If you need a same day or next day ride YOU MUST call Member Services at the number above and do not fill out the remainder of this form.

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

First NameLast Name
South Country Member ID Number*
Number from the South Country ID card that starts with a G and ends in 01. Only add the 8 numbers between.
Member date of birth*

MonthDayYear
Date
!

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.

Parent/Guardian Transportation Authorization for minors under 18
Age

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

MonthDayYear
Contact first and last name*

First NameLast Name
Contact phone number*
Please enter a valid phone number.
Contact Email
Contact 1 relationship to member*
Alternate contact first and last name

First NameLast Name
Alternate contact phone number
Please enter a valid phone number.
Alternate contact relationship to member

Ride Request Screening/Eligibility