Tuscarawas County Job & Family Services

Please Note: Emails can take from 1 hour to 24 hours for us to receive after you have sent them. We must receive your email before 2:30 p.m. each day, 48 hours before your appointment, not including weekends and holidays. If you have any doubts, please call us with your request.

Transportation Request

Date and Time of Appointment

Date *

Time *HHMMAM/PM

Length of Appointment (Estimate if needed) *

Client Information

*** Clients under 18 years of age must be accompanied by a parent or guardian. ***

Social Security Number *

Medicaid Eligible Patient/Client Last Name *

Medicaid Eligible Patient/Client First Name *

Parent/Guardian Last Name (If patient/client is under 18 years of age.)

Parent/Guardian First Name (If patient/client is under 18 years of age.)

Client Street Address *

Client City *

Client State *

Client Zip Code

Phone *

Destination Information

Destination Name *

Destination Address *

Destination City *

Destination State *

Destination Zip Code

Pharmacy

Will you need to go to a pharmacy after your appointment? *

YesNoMaybe

Pharmacy Name

Pharmacy Address

Vehicle Needs

Total Passengers (including client) *

Do you need a handicap van? *

YesNo

Child Car Seat (How many?)

Child Booster Seat (How many?)

Email & Notes

Client's Email Address *

Special Assistance Needed and Other Information

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank: