Submit a request – Veyo RideView Support

Your email address

Subject

What State Are You In?

What type of help can we assist with?

https://ct.ridewithveyo.com/complaints/

** To file a grievance, please copy and pate this link into your browser and fill out the form **

*If the member would like to file a grievance, please contact the member's health plan*

How can we help?

Preferred Provider Name

Details

*If this concern is urgent, please contact the Veyo Call Center immediately*

What type of RideView Technical Support is needed?

Member's Health Plan

Is this a Discharge?

Does your member require assistance to and from the vehicle

What is the passenger's ID (MID/AHCCCS ID/etc.) *If Account Pay, put Facility Name*

ForwardHealth ID#

Enter the Member's ID for the form you are submitting. If there is more than one member please indicate that in the description below.

Member First Name

Member Last Name

Member Phone Number

Member Date of Birth (Or Account Pay Facility Name)

Member ID

Trip Date

Who is receiving the compliment?

What is the name of the person receiving the compliment?

If you do not recall the name, please provide any informative and/or descriptive details in the Description box below

What was the date of the interaction?

What was the approximate time of the interaction?

Trip Date(s)

Facility Name

Facility Address

What is your job title at your facility?

Facility Name

Facility Contact Name

Your Name

Your phone number

Please provide the best number to call for additional questions.

What is a good contact number to reach you at?

Passenger First Name

Passenger Last Name

Member's MID

Please enter the medical ID number for the member.

Confirmation Number

Please enter the trip confirmation number

What was the name of the Agent that was spoken to?

Please provide the agent's name if you recall

What was the date of the call?

Was the trip going to or leaving your facility?

What number did you or the member call?

What number did you or the member call from?

What was the approximate time of the call?

If preferred, you may also attach your schedule using the attachments section below,

Do your holiday hours differ than your normal hours? If so, please provide those details.

Facility Address

What dates are these closures?

What holidays is your facility closed on?

RideView Trip Rescue Disclaimer

In order to process your trip rescue, we will need either a screenshot of the trip in RideView, or the open trip card with ALL member/trip details and upload the screenshot in the attachments portion (add or drop files here) below. If you do not have a screenshot, please fill out as much detail below to assist us with your trip rescue. Please be sure to include your email so we can respond quickly to your urgent request. Note: Only one form per member, this will allow an agent to work on your request quickly.

Member Form(s) Selection

Please indicate which form(s) are being submitted.

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

I Agree

Any attached forms have been signed by the appropriate health care professional and all necessary information has been filled out including at least 3 of these member details: Member Name, Member ID, Date of Birth, and/or Member Address. Forms missing this information will be sent back to be completed again.

Attachments

Add file or drop files here