Attachment G.pdf

DSS Form 37708 (JUL 24) Page 1 of 2

TRANSPORTATION REQUEST FORM

TRANSPORTATION INFORMATION

Transportation Request Type

Therapeutic (ISCEDC)

BID

Regular Foster Care (RFC, DCBR, Special Needs)

Initial or Corrected Request?

Initial Corrected

Date Requested

Transport Begin Date Transport End Date (if one day only, use same date as the begin date)

Client exposed to COVID19?

Yes No

Purpose of Transport Family Visitation Court Hearing Pre-Placement Visit Adoption Event Placement Change (Must be approved via email from Well-Being Manager or designee. Case manager must meet the client for admission. This form is not to be used for Emergency Placement Transports.)

Other: (If other, describe purpose.)

MODIVCARE DENIAL INFORMATION (Required for medical, dental, and vision therapy transportation.)

Denied by Modivcare?

Yes No Date Denied Denied by (Modivcare Employee)

Denial reason (required for medical transports) Less than 72-hour notification Distance exceeds mileage allowed Client not appropriate for transport

If “Client Not Appropriate for Transport,” list reason.

Behavioral Medical Complications Other:

Is the client under the age of 14 and does not have an adult that can accompany them during transport?

Yes No

CLIENT INFORMATION

Client Name CAPSS Case ID Client DOB Client Gender

If siblings are being transported, list siblings name(s)

Case Manager Name and Phone Number DSS County Office DSS Region

Emergency after hours contact name and number (REQUIRED) (If Regular Foster Care, email invoice to rfctransportinvoices@dss.sc.gov.)

CAPSS Person ID mailto:rfctransportinvoices@dss.sc.gov

DSS Form 37708 (JUL 24) Page 2 of 2

Signature of Transport Approver Approval is represented when form is emailed to the Regional Transportation Email AND the Foster Care Team Leader for Therapeutic and RFC transports, and the Regional Transportation Email AND Educational Liaison for BID school transports.

PICK UP, DROP OFF, AND RETURN INFORMATION

Pick Up Location Name, Address, and Description (i.e. DSS office, foster home, group home, etc.)

Pick Up Time Pick Up Contact Name Pick Up Contact Phone

Destination Location Name, Address, and Description (i.e., DSS Office, foster home, group home, etc.)

Estimated Time of Drop Off Destination Contact Name Destination Contact Phone

Is a return trip needed?

Yes No

Pick Up Time for Return Trip

Return Location Name, Address, and Description (i.e., DSS Office, foster home, group home, etc.)

Estimated Time of Return Return Contact Name Return Contact Phone

Is a Driver Assistant Needed?

Yes No

If Yes, Explain Why Driver Assistant is Needed

Is Wait Time Needed?

Yes No

If Yes, How Long Will Wait Time Be?

Why is Wait Time Needed?

Is Car Seat Required?

Yes No

If Yes, indicate type of car seat needed Rear Facing Forward Facing Belt Positioning Booster

Comments or Special Concerns (Cancellations are the responsibility of the case manager.)

If a driver is not available on the date requested, is there an alternate date you would like to request?

***DO NOT ENTER INFORMATION IN THIS SECTION*** (FOR CONTRACT STAFF ONLY)

Provider Name

Driver Name Driver Contact Info

Driver Home Base Address (Point A)

Youth Pick Up Address (Point B) Total Mileage from A to B

Youth Drop Off Address (Point C) Total Mileage from B to C

Driver Home Base Destination (Point D) Total Mileage from C to D

Total Mileage Roundtrip (A+B+C+D) Total Mileage Cost Total Wait Time Total Wait Time Cost