Ride Request Form Logo
  • 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.
  • Member is not eligible for RideConnect services.

    Stop here.

  • Stop here.

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

     

  • 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.

  • 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.

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  • !

    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

  • 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.
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  • Mode of Transportation

  • Appointment Information

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  • !

    This request will be less than the 3 days required by RideConnect. Please call us at 1-866-567-7242 M-F between 8 am and 4:30 pm to set up a ride with less than 3 days notice.

  • !

    RideConnect can schedule 30 days out, except for dialysis rides.

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    A separate ride request form will need to be completed with those ride details. Only one ride request my be entered per form.

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    Member must have an accompanying passenger for this ride to be scheduled.

  • Click Next to REVIEW the form information.

    For accuracy, please review all information entered for this ride request. RideConnect will enter the request as received. It is your responsibility to ensure that all details are accurate so that the member receives the correct transportation services. Click Back to edit information.

  • Please review you answers and hit submit to continue.

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