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Parameters of Service
Todays Date
Name
Phone Number
Email
Partner Agency
Title
Fax
Who is being referred to Rides to Wellness? How will changes in eligibility be given to MTC?
For what purposes do you authorize to use Rides to Wellness services?
What origins or destinations do you authorize?
Pharmacy
Hospital Discharge
Grocery Store
Court House
Other
Dentist
Home
Community Mental Health
State Offices
Hospital
Substance Abuse
Dialysis
Personal Errands
What origins or destinations do you authorize?
Any
Pre Authorize Only
None
Please describe your scheduling process:
Please describe your scheduling process:
Email (to above address)
Mailed
Fax
Notes
Download File
Extras
Timezone:
EST - Eastern Standard Time
Group:
MTC
Currency:
USD - United States Dollar
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Thank you for your submission. In the event your registration is approved, you will receive an email with further instructions.