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New Entry: Driven to Care Application
Thank you for submitting a Driven to Car application. Our goal is to eliminate as many barriers to care as possible. We will be in contact within two to three business days.
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Name
*
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Last
Today's Date
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Email
Address
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Phone
*
Referral Source
Medicaid Eligible?
*
Service Requested
*
Volunteer Ride
Gas Card
Transit Passes
Location of appointment at JRMC
*
RADIOLOGY
CLINIC
REHAB
LAB
SURGERY CENTER
CANCER CENTER
OTHER
Please define if OTHER
*
Time of appointment at JRMC
*
Pick-up/Drop-off
*
PICK-UP
DROP-OFF
BOTH
Pick-up Time
Drop-off Time
Do you have any health concerns or needs that a volunteer driver should know?
Would a volunteer of the opposite sex be acceptable?
*
YES
NO
Emergency Contact Information
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