Submit a request

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

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.

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

Please enter the medical ID number for the member.

Please enter the trip confirmation number

For multiple trips please list all trip numbers In the description below.

Please provide the agent's name if you recall

Enter Transportation Provider's Name

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.

Select which form(s) are being submitted. (Please note only 5 attachments can be submitted at a time)

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

Add file or drop files here