Disclaimers: This form may be used for new ride requests and if your appointment date is 5 business days or more before your ride request. Call BlueRide Member Services (866-340-8648) if: You're calling for a ride less than 5 days before your appointment date You need to schedule a multi-stop ride You need to make a change to your ride (edit, cancel, etc.) What you should know after you send the form in: Please allow 48 hours for your ride to be scheduled. Once your ride has been set up, you will get an email from BCBSMN with the company name, their phone number and your ride details. Call the ride company two days before your ride to make sure it was received. For your return ride, you must call the transportation company. Member Information: Member First Name Member Last Name Blue Cross and Blue Shield Member ID? Date of Birth Phone Number If you're trying to schedule a ride for a member under 12 years old, please call Blue Ride Member Servies at 866-340-8648 - Opens in a new window. Email Address (for ride request follow up) Please make sure that your email address does not contain any spaces or special characters. Are you the member filling this form out for yourself? Yes No Your Information: What is your relationship to the member? Your phone number Your first name Your last name Are you calling from an organization (facility, agency, etc.)? Yes No Agency Name/Facility Your title and NPI # Ride Type: Do you need help getting to and from the vehicle? Yes No Which of the following do you need assistance with? Walking Wheelchair Stretcher Which of the following best describes your wheelchair? Extra Wide Electric Powered Power Scooter Standard Which of the following best describes your stretcher? Standard Extra Large (Bariatric) Enter the total weight (pounds) of yourself and your equipment Trip Details: Ride date What time is your appointment? Your appointment is less than 5 business days away. To schedule a ride within this shorter timeframe, please call BlueRide Member Services at 866-340-8648 - Opens in a new window. Rides cannot be scheduled more than 31 days out. Please call BlueRide at 866-340-8648 - Opens in a new window for additional information. Appointment type Autism Behavioral Health Dental Dialysis Discharge Fitness Methadone Nursing Home Pharmacy Primary Provider Visit Specialist Provider Visit Is anyone else riding with you? Yes No Number of adults riding with you Number of children riding with you Will you be using a car seat? Yes No The transportation company can provide 1 car seat. Please select "Yes" if you need one provided. If additional car seats are needed, you will need to provide those. Yes, I need one provided by the transportation company I will provide my own car seat(s) What type of car seat is needed? Forward facing Rear facing How many car seats will you be providing? Will you be using a booster seat? Yes No The transportation company can provide 1 booster seat. Please select "Yes" if you need one provided. If additional booster seats are needed, you will need to provide those. Yes, I need one provided by the transportation company I will provide my own booster seat(s) How many booster seats will you be providing? Pick Up Details: Pick up location Home Other Pick up location name (work, relative's house, friend's house, etc) Address City/Town State - Select -IowaMinnesotaNorth DakotaSouth DakotaWisconsin ZIP/Postal Code Drop Off Details: Drop off location (hospital, clinic, etc) Address City/Town State - Select -IowaMinnesotaNorth DakotaSouth DakotaWisconsin ZIP/Postal Code Ride type One-way Round-trip Post-Appointment Drop Off Details: Is your post-appointment drop off location the same as where you were picked up? Yes No Post-appointment - drop off location Home Other Post-appointment - drop off location name (work, relative's house, friend's house, etc) Address City/Town State - Select -IowaMinnesotaNorth DakotaSouth DakotaWisconsin ZIP/Postal Code Are there any special instructions you would like us to be aware of?
