a. Your date of birth, first and last name and phone number.

b. Medicaid ID number.

c. Your doctor’s or facility’s name, address, and telephone number.

d. The date and time of your medical appointment.

e. Full starting and destination (drop off) addresses.

f. Whether it is a round trip or a one-way trip.

g. If you will have a personal care attendant, or PCA.

h. If you can walk without help, or if you have a mobility device. We may ask if you need assistance from the driver.

i. If you use a mobility device, we may ask:

i. What type of mobility device you use (for example, wheelchair, scooter, crutches, or walker).

ii. Its measurements.

iii. If your mobility device has changed since we last transported you.