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.

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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?

Dream Care Rides is a private-pay service: trips are billed to your facility account or paid by the patient directly. We do not bill Medicare or commercial insurance (insurance riders are served through our provider partners), and Medicaid is limited to trips starting within 6.5 miles of our Olympia Fields or Palatine bases.

Facility Account

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

Medicaid (limited service area)

Only for trips starting within 6.5 miles of our Olympia Fields or Palatine bases. DCR bills Illinois HFS; your facility is not invoiced.

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