Transportation Application

The Transportation Disadvantaged Program was established to provide transportation services to the elderly, disabled, economically disadvantaged, children at risk and to individuals who have no other forms of transportation. It is our goal to provide citizens with safe, reliable, convenient, affordable and cost efficient public transportation. For more information, please call BCCOA transportation department at 904-259-9315.

Household Member & Total Household Income:

Household Member 1
$
.00
Household Member 2
$
.00
Household Member 3
$
.00
Household Member 4
$
.00
Availability of Transportation

What type of vehicle do you own

Information About Recurring Medical Appointments
Hours

Days of Week*

Hours

Days of Week

Special Needs*

Please check any special needs, services or modes of transportation you require during transportation

Certification and Acknowledgment

I understand and affirm that the information provided in this application for CTD Medicaid Non-Emergency Transportation (NET) services is true and correct, to the best of my knowledge, and will be kept confidential and shared only with medical and transportation professionals involved in evaluating and determining my needs for transportation to and from medical appointments. I understand that providing false or misleading information, or making fraudulent claims, or making false statements on behalf of others constitutes a felony under the laws of the State of Florida.

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