Transportation Scope of Work Service Coordinator(Required)Purpose of Scope of Work(Required)Start ServicesStop ServicesEnd of MonthVendor DetailsVendor Name(Required)Vendor Phone Number(Required)Primary Vendor Email(Required) Secondary Vendor Email Additional Vendor Email Client DetailsClient Name(Required)Client Date of Birth(Required) Client Phone Number(Required)Client Email Client Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Case Manager Email(Required) Additional DetailsStop ServicesServices must not be provided after the date listed below. Any services delivered beyond this date will not be eligible for payment.End Date(Required) Service & Pricing DetailsStart Date(Required) Services are not authorized before this date.End Date(Required) Services are not authorized after this date.Services Provided(Required)Scheduled RidesFlexible Use RidesBoth Flexible & ScheduledMax Monthly Budget(Required)Ride Type(Required) Ambulatory Walker Foldable Wheelchair Accessible Electric Wheelchair Accessible Stretcher Transport Required Other Assistance at Vehicle Needed?(Required) Yes No Assistance is limited to transportation-related needs and does not include personal care services or physical lifting of individuals.🚗 Vehicle Entry & Exit Assistance is provided to help individuals safely enter and exit the vehicle. This may include opening and closing vehicle doors, assistance with seat belts, and support with mobility devices such as walkers, canes, or wheelchairs during boarding and exiting. 📍Curb-to-Curb Assistance is provided from the pickup curb location to the destination curb location. Drivers may assist individuals with entering and exiting the vehicle, but riders are responsible for independently traveling between the vehicle and the building entrance. 🚪Door-to-Door Assistance is provided from the individual’s door or building entrance to the destination door or building entrance. Drivers may provide limited assistance to help individuals safely travel between the vehicle and the entrance when needed. Scheduled RidesNumber of TripsFrequencyWeeklyMonthlyOne TimeTrip Type One Way Trip Round Trip Cost per TripRide DetailsPickup Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dropoff Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CAPTCHA
