Request Transportation

For private-pay clients, families, caregivers, and responsible parties requesting non-emergency transportation. Complete the form below and a member of our team will follow up to confirm your trip details.

Please do not submit patient medical information, diagnosis information, Social Security numbers, insurance details, or private health information through this form. This form is for transportation coordination inquiries only.

Passenger Information

Passenger Name*

Phone Number*

Email Address

Mobility Needs*

Trip Details

Trip Type*

Preferred Pickup Date*

Preferred Pickup Time

Pickup Address*

Drop-off Address*

Additional Notes

Special Considerations or Notes

Required Acknowledgments

I understand that Element Non-Emergency Medical Transport provides non-emergency transportation only and does not provide ambulance transport, emergency response, medical treatment, or 911 services.

I confirm that the information provided in this request is accurate and that this request is not for an emergency situation. If this is a medical emergency, I will call 911.

Fields marked * are required. We'll follow up by phone or email to confirm your trip.

Prefer to Call?

864-208-5555 [email protected]

Are You a Facility?

Hospitals, skilled nursing facilities, and care partners should use the Facility Partnership Inquiry form.

Facility Partnership Inquiry →

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