Urgent Transport Request

For same-day or next-day transport needs. For immediate dispatch, call (708) 505-6994 directly.

Urgent Patient Transport

Hospital discharges, ER transfers, and time-critical transport. Reduced required fields for speed. For scheduled (non-urgent) transport, use our Standard Request Form.

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Urgency Details

Urgency Level *

Immediate (within 2 hours)Same Day (today)Next Business Day

Reason for Urgency *

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 *

Pickup Address *

Room / Unit / Floor

Drop-off Address *

Room / Unit / Floor

Round trip?

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.

I confirm that [Facility Name] guarantees payment for this urgent transport if the selected payment channel (broker authorization, Medicaid, etc.) does not cover the trip. The facility accepts responsibility as the payer of last resort at Dream Care Rides' private-pay rates.

Urgent dispatches are prioritized. This guarantee ensures the driver is compensated regardless of insurance or broker outcomes.

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

For immediate dispatch, call (708) 505-6994

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