Book a Ride

By booking online, you will receive a 5% discount. Plus, if you pay the same day, you will receive another 5% discount!

This form can be used to book trips and to get cost estimates. You can select the appropriate option in the form. Transportation booked online must be submitted before 6pm the day prior to transport. Otherwise, we can’t guarantee it can be scheduled. Please call our office at (503) 569-7070 to arrange same-day transportation.

Trip Booking Form

If you are human, leave this field blank.

Medicaid / OHP Client? *

Yes

Is the client to be transported covered for a transport benefit under Medcaid / OHP or other Care Organization?

Is the trip you're booking for today? *

Yes

Is this trip reservation for the same-day or are you booking a ride for tomorrow, after 6pm today?

*** STOP - IMPORTANT NOTICE ***

Those who are members of the Oregon Health Plan or another Care Organization that are provided the Medicaid Transportation benefit must contact the appropriate brokerage for transportation.

Medical staff or others authorized to book trips for Medicaid clients (normally after-hours) should note that we make no guarantee that submissions via this form are HIPAA compliant transmissions.

Those submitting requests for those covered under Medicaid will be responsible for any bills associated with the requested trips.

*** STOP - IMPORTANT NOTICE ***

To arrange same-day transportation or if it's after 6pm and you're trying to schedule a trip for tomorrow, you must call us at (503) 569-7070. We cannot guarantee trip reservations for submissions outside of these guidelines.

To continue please answer both of the required questions above.

Client Information

The primary individual to be transported. Please ensure this information is accurate so we can determine if this client has an existing customer record with us.

First Name *

Last Name *

Date of Birth *

Contact Phone *

The clients or pick-up facilities contact number, to be used for communication about transport.

Trip Reservation Information

Type of Request *

Type of Trip *

Use multi-destination for 2 leg trips that aren't returning to the original pick-up.

Method of Transport *

Reason for Trip * Reason for Trip

*** Just Checking ***

You have selected that this trip is a Cost Estimate Only. Please note that this will not result in a trip being booked until we contact with you pricing information and then receive an additional notice from you to actually book the trip and receive additional information for billing. If you're aware of our pricing then we suggest selecting Trip Booking to save time.

*** Just Checking ***

You indicated that the trip is a facility transfer. Typically these trips are one-way. Be sure to double check those values above.

*** Just Checking ***

You indicated that the trip is a hospital discharge. Typically these trips are one-way. Be sure to double check those values above.

Additional Services

Provide Wheelchair

Provide Oxygen

Large Wheelchair/Powerchair? *

Yes

Is the clients wheelchair/powerchair more than 32 inches wide?

Actual Chair Width *

Measured from the outside of the wheels/grips

Client Weight *

Weight in pounds (lbs)

Powerchair Weight *

Weight in pounds (lbs) of the powerchair

Wheelchair Weight *

Weight in pounds (lbs) of the wheelchair

Client Height *

*** STOP - IMPORTANT NOTICE ***

The wheelchair/powerchair size you've indicated is close to or exceeds the capabilities of the lifts and ramps manufactured on the market. Know that Willamette Valley Transport has several vehicles equiped with large lifts/ramps to handle bariatric needs. Please contact our office so we can discuss the options we have to assist you. One of the commen solutions is to transport by Stretcher.

*** Just Checking ***

You indicated that the trip is a hospital discharge. Typically these trips are one-way and/or involve is providing a wheelchair. Be sure to double check those values above. Otherwise continue on.

*** Just Checking ***

You indicated that the trip is a facility transfer with a wheelchair. Typically these trips are one-way and/or involve is providing a wheelchair. Be sure to double check those values above. Otherwise continue on.

*** Just Checking ***

You indicated a Ambulatory method of transport but have requested we provide a wheelchair. This is only possible if the client can get into/out of our transport vans with little or no assistance. Please double-check your selections.

*** Just Checking ***

You indicated a transport by Stretcher but have requested we provide a wheelchair. Please double-check your selections as this appears to be invalid.

*** Just Checking ***

You indicated a transport by powerchair but have requested we provide a wheelchair. Please double-check your selections as this appears to be invalid. If your idea was to have us provide a powerchair we regrettably are unable to do so for insurance and reasons.

*** STOP - IMPORTANT NOTICE ***

To help ensure we can provide the approperiate equipment and needs for transport of this client you will need to contact us by phone to arrange this trip.

The indicated combined weights are not supported by all of our vehicles.

*** STOP - IMPORTANT NOTICE ***

To help ensure we can provide the approperiate equipment and needs for transport of this client you will need to contact us by phone to arrange this trip.

The indicated weight is not close to or not supported by all of our stretchers capabilities.

Care Attendants and/or Extra Passengers?

Care Attendant

Passenger(s)

Select all that apply.

Total additional Riders? *

NOT including the client being transported

Information on Riders

You can provide some notes regarding those riding with the client.

Location & Time Details

Date of Transport *

Number of Destinations *

For anymore than 3 destinations (4 trip legs) your trip must be booked by calling us.

Please note that you're requesting a trip that spans more than 1 calendar day it must be booked as two seperate reservations.

Pick-Up Location Name

The name of the doctors office, facility, etc.

Pick-Up Address *

Unit #

Google Map

Appointment / Drop-Off Time

Set my own Pick-up Time?

Yes

We typically set the pick-up time based upon the appointment time and our systems calculated travel and loading/unloaded times to ensure on-time arrival. By using this option we cannot guarantee an on-time arrival to your appointment.

Pick-up Time *

Please note that our drivers may arrive 5-10 minutes before the time you set here.

*** NOTE ***

Just as a helpful note related to correspondence, this trip will likely be dispatched by our Salem Branch based upon the address of origin you've indicated.

*** NOTE ***

Just as a helpful note related to correspondence, this trip will likely be dispatched by our Portland Branch based upon the address of origin you've indicated.

Drop-Off Location Name

The name of the doctors office, facility, etc.

Drop-Off Address *

Unit #

Google Map

Pick-up Time Preference *

The estimated time can help us with our planning to reduce waiting times when compared to a normal will-call option.

Pick-up Time from 1st Destination *

2nd Stop - Drop-off Location Name

The name of the doctors office, facility, etc.

2nd Stop - Drop-off Address *

Unit #

Google Map

Pick-up Time Perference (From 2nd Stop) *

The estimated time can help us with our planning to reduce waiting times when compared to a normal will-call option.

Pick-up Time (from 2nd Stop) *

Return To Original Pick-up Address?

Yes

Return To Address *

Additional Information

Please provide any additional information that would be helpful in making this reservation.

Requester Information

Provide your information below

Are you the client being transported? *

First Name *

Last Name *

Relation to Client *

Relationship * Relationship

Facility / Organization *

The name of the facility you work for

Position *

The title of your position

Phone Number *

Email Address *

This must be a valid email as we we will contact you by this method to confirm your reservation. Otherwise you may not be eligible for your 5% online discount.

Billing / Payment Information

Who is paying the bill? *

Please note that we cannot bill private insurance as most non-emergency transport is not covered.

Sent in Care Of?

Yes

When sending the bill to the client should we address someone "care of"?

Send in "Care Of" (C/O)

Who is the person to be addressed care of, ie who handles bills on behalf of the client?

Third Party Billing Contact

Please provide the name or company of the third-party paying the bill

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Billing Phone *

Billing Email

Billing Method *

Payments made same-day are eligible for an additional 5% discount.

Payment Type *

Please note that any dishonored checks will result in a $25 fee in addition to fees accessed by our bank. Same-day discount will not apply upon rebilling.

Please note that since a third-party (without an email) has not been specified, invoices will only be sent by email.

If a mailed invoice is required upon receiving failed delivery notices to an incorrect email, the 5% online booking discount may be voided.

Signature *

Draw It
Type It
Clear

You hereby acknowledge and agree with your electronic signature above; to pay any costs related to your transport and that Willamette Valley Transport cannot bill private insurance. You understand that you may submit your own claims to insurance or other third-parties but understand that our non-emergency medical transport is not covered by most insurance plans.

Book a Ride

Trip Booking Form

Client Information

Trip Reservation Information

Location & Time Details

Requester Information

Billing / Payment Information

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