Forms and Applications

Do you need help getting back and forth to your medical appointments? If you are on Medicaid, do not have access to a vehicle, and your physician can verify a medical need, you may be eligible for our Non-Emergency Medicaid transportation program. This program will assist you by providing you a ride to and from your Ohio Medicaid providers located in Lucas County.

To apply for Non-Emergency Medical Transportation you will need to submit the following forms:

• Medical Needs Assessment (852) (PDF)
  • This form must be completed by ONE of your physicians or ONE of your medical providers.
  • List all of your physicians and medical providers. You may list one pharmacy. All addresses must be complete and include name, address, state, zip code and phone number.
  • Please select ONE transportation contractor.

  Reporting Changes

  Reporting changes within 10 days to your case worker is very important. You will need to report a change if:

  • Your household composition changes
  • You move
  • You have a child
  • Your income or monthly bills change

  OR

  Even though the preferred method of change reporting is the online benefit application, you may also call the agency to report changes. Any change regarding Cash Assistance, Food Assistance, Medical or Work Activities, please contact the agency call center at 1-844-640-6446.
  
  Drop Off