Non-Emergency Transportation

The Non Emergency Transportation (NET) program is designed to increase access to medical or counseling appointments for Medicaid eligible individuals.

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Online by completing and submitting the form below, or
Print a Transportation Request Form by clicking Here and return via:
Call the FCJFS Transportation Team at (740) 652-7682, or toll free at 1-800-450-8845

Call the FCJFS Transportation Team at (740) 652-7682, or toll free at 1-800-450-8845

You must submit your request at least five business days before your medical appointment.
Transportation customers must sign a Rights and Responsibilities form.
The Rights and Responsibilities form will be mailed to you upon receipt of your request.
If you are on a Managed Care Plan, you can also use their transportation services.

You will be contacted within 24 hours upon receipt of your request to confirm or deny the transportation

Transportation Request

FAIRFIELD COUNTY JOB & FAMILY SERVICES

CUSTOMER NET TRANSPORTATION REQUEST

Patient Name Social Security# Requestor's Name(if not the Patient) Requestor's Orginization Requestor's Phone Number(To contact if there are questions about this request)
Address
Phone Alternate Phone
Appointment Date Appointment Time
Name of Doctor Address of Doctor
Special Needs
Care Giver	Car Seat	Lift Van
Oxygen	Wheelchair	Other

FCJFS will contact you within 24 hours upon receipt of your request to either confirm or deny.

If you have additional appointments, please use this form.

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