Declaration form

DECLARATION: I do not have any means of transportation that is of no cost to the state of Colorado.Without reimbursement from the State, I would not be able to attend medically necessary appointments. I understand the trip must be the most direct route to and from the appointment with the closest qualified provider.

I authorize release of medical information necessary to process this request.

This form must be signed by applicant/parent or guardian and returned to MedRide.