Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your chosen editor.
2. In the Referring Agency Info section, fill in the requesting agency name, today’s date, your name as the requestor, and a phone number where you can be reached. Indicate whether the client has been informed of this referral by selecting ‘Yes’ or ‘No’.
3. Provide the client’s email address if applicable.
4. In the Bus Tickets section, choose the type of tickets needed for the client by checking the appropriate boxes for Fixed Route or Dial-A-Ride. Include a copy of their ADA card for tickets.
5. For EHP Medi-Ride transportation requests, specify the type of vehicle required (Car, Wheelchair Van, Gurney Van) and note any comments or concerns regarding the driver.
6. Justify why the service is needed. Include specific appointments in the provided fields: Doctor/Hospital name, type of medical practice, date(s) and time(s) of appointments, address, whether the appointments are roundtrip, length of appointment, and if an escort will accompany the client.
7. Complete the Required Info About the Client section by providing the client’s name, phone number, street address, city, zip code, date of birth, primary language, caregiver or alternate contact’s name and phone number, marital status, and gender.
8. Indicate if the client lives alone or not and their income status relative to the federal poverty level.
9. Select the ethnicity and race as applicable.
10. In the Daily Activities section, indicate the level of assistance needed for various tasks, such as eating, dressing, and managing medicines.
11. Once all sections are completed, review the information for accuracy. Save your changes, then download or print the form for submission.

Complete the CA VCAAA Transportation Referral Form online today to assist users in accessing vital transportation services.