Refer Someone for Transportation

For case managers, discharge planners, social workers and partner agencies. Only refer with the rider's permission.

COCAS Transportation Assistance is not an ambulance, emergency-response service or 911 substitute. For a medical emergency or immediate danger, contact local emergency services (911).

Referring organization

Referral source

Organization

Your name *

Your role

Your contact

Your email

Rider information

Rider name

Rider phone

Rider email

State

County

Trip details

Trip purpose

Urgency

Trip date

Trip time

Pickup

Destination

Mobility needs

Passenger count

Funding

Discharge deadline (if applicable)

Safety considerations

Permission and safe contact

Authorization to contact the rider *Authorization to share rider information with an approved transportation provider

Safe-contact instructions

Important Information

This is a transportation-safety screening, not a medical diagnosis or emergency evaluation.

Before you submit

COCAS Transportation Assistance is a non-emergency transportation-support and coordination program. Transportation availability, eligibility, cost, funding, provider assignment and accommodations must be confirmed before a trip is considered scheduled.