Services | Transit To Care

Schedule a Ride

This form for EXISTING customers ONLY. New customer, please contact us to verify your eligibility Schedule a Ride: (719) 644-6005 or click on Schedule a Ride 24/7 Also, you can download this form, fill it out and fax it to (719) 888-2929 Effective 05/01/2024, ALL round trips that exceed 52 miles are temporarily suspended until further notice.

Schedule a Ride Online: Trip Information

First Name: *

Last Name: *

Date of Birth *

Gender *

Medicaid Number *

Phone *

Home/Pick-up Address

Street Address *

City *

Zip Code *

Destination Address

Street Address *

City *

Zip Code *

Appointment Date *

appointment Time *

Return Time *

Notes/Comments:(If client requires special assistant please specify below) Please: Be as descriptive as possible

Agreement and Signature

I certify that the information provided is accurate to the best of my knowledge. If Transit To Care does not receive required documentation, if applicable, within one business day of the initial request date, the request will be denied. DENIED REQUESTS CAN ALWAYS BE RESUBMITTED WITH THE REQUIRED DOCUMENTATION.

Type your name to denote signature *

Date Signed *