Call 911 if you experience:

•Chest pain or difficulty breathing
•Stroke symptoms (face drooping, arm weakness, speech difficulty)
•Severe bleeding or broken bones
•Loss of consciousness or seizures
•Severe allergic reactions

Request Patient Transport

Submit a transport request for your patient. Our dispatch team confirms all trips within 2 business hours. For same-day or urgent needs, use our Urgent Request Form or call (708) 505-6994.

Requesting Facility

Facility Account #

Your DCR account number (provided during onboarding). Leave blank if unknown.

Facility Name *

Your Name *

Your Phone *

Your Email *

Patient Information

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Phone

Patient Weight (lbs)

Required for bariatric or stretcher transport.

Mobility Status *

Special Needs / Accommodations

Trip Details

Trip Date *

Pickup Time *

Appointment Time

If different from pickup time. We plan arrival 15 min before appointment.

Pickup Address *

Room / Unit / Floor

Drop-off Address *

Room / Unit / Floor

Round trip?

Is this a recurring/standing order?

Who Is Paying for This Trip?

Facility Account

Bill to our facility account. Invoice per our payment agreement with DCR.

Medicaid Fee-for-Service (FFS)

DCR bills Illinois HFS directly. Patient must have active Medicaid FFS coverage.

Medicaid MCO (via Broker)

Trip authorized through a transportation broker. DCR bills the broker.

Patient Private Pay

Patient pays DCR directly. Credit card required at time of service.

PO # / Reference #

Optional. Include if your facility requires a PO number on the invoice.

Patient Insurance Info (Optional)

Attach patient insurance info for your facility's records?

This info is for YOUR facility's billing purposes. DCR does not bill these insurers.

Additional Trip Notes

Need help? Call (708) 505-6994

Dream Care Rides | 20000 Governors Dr Suite 103H, Olympia Fields, IL 60461 | (708) 505-6994

Request Patient Transport

Submit a transport request for your patient. Our dispatch team confirms all trips within 2 business hours. For same-day or urgent needs, use our Urgent Request Form or call (708) 505-6994.

Requesting Facility

Facility Account #

Your DCR account number (provided during onboarding). Leave blank if unknown.

Facility Name *

Your Name *

Your Phone *

Your Email *

Patient Information

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Phone

Patient Weight (lbs)

Required for bariatric or stretcher transport.

Mobility Status *

Special Needs / Accommodations

Trip Details

Trip Date *

Pickup Time *

Appointment Time

If different from pickup time. We plan arrival 15 min before appointment.

Pickup Address *

Room / Unit / Floor

Drop-off Address *

Room / Unit / Floor

Round trip?

Is this a recurring/standing order?

Who Is Paying for This Trip?

Facility Account

Bill to our facility account. Invoice per our payment agreement with DCR.

Medicaid Fee-for-Service (FFS)

DCR bills Illinois HFS directly. Patient must have active Medicaid FFS coverage.

Medicaid MCO (via Broker)

Trip authorized through a transportation broker. DCR bills the broker.

Patient Private Pay

Patient pays DCR directly. Credit card required at time of service.

PO # / Reference #

Optional. Include if your facility requires a PO number on the invoice.

Patient Insurance Info (Optional)

Attach patient insurance info for your facility's records?

This info is for YOUR facility's billing purposes. DCR does not bill these insurers.

Additional Trip Notes

Need help? Call (708) 505-6994

Dream Care Rides | 20000 Governors Dr Suite 103H, Olympia Fields, IL 60461 | (708) 505-6994