📅 Request a Ride

Fill out the form below to request your ride. For immediate scheduling, call 724-977-0049 anytime.

Please allow 24–48 hours advance notice when possible. Same-day? Call us directly at 724-977-0049.

💡 Your insurance, MATP, CTS, or MTM may cover this ride at NO cost to you! Include your insurance info below and we'll help verify your coverage.

👤 Passenger Information

First Name *

Last Name *

Phone Number *

Date of Birth

Caregiver / Alternate Contact Phone

📍 Pickup & Drop-Off Details

Requested Date *

Requested Pickup Time *

Appointment Time (if applicable)

Pickup Address *

Are there steps at the pickup location? *

Drop-Off Address *

Destination / Facility Name

Return Trip Needed?

♿ Transportation Type *

Select the transport type that best fits the passenger's needs:

🚶

Ambulatory

Can walk / minimal help

♿

Wheelchair

Manual wheelchair

🛵

Motorized Scooter

Power scooter user

🛏️

Stretcher

Must remain lying down

Do you need us to provide a wheelchair?

Additional Mobility / Special Notes

🛡️ Insurance / Coverage Information

Coverage / Payment Type

Member ID / ACCESS Card Number

Group Number (if known)

Purpose of Trip *

📝 Additional Notes

Anything Else We Should Know?

How Did You Hear About Us?

✅ Your ride request has been submitted! We will contact you within a few hours to confirm. For urgent requests, call 724-977-0049 directly.

By submitting this form you agree to allow Prompt Care Transportation to contact you about your transportation request.