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MAILING ADDRESS:
PO BOX 360943
Birmingham, AL 35236-0943

STREET ADDRESS:
12 Office Park Circle, Suite 115
Birmingham, Al 35223

PHONE:
800-543-7143
205-978-1000

FAX:
205-978-1019

Request A Ride:

Kid One can schedule transportation for appointments up to 30 days in advance.

Client Information

Is the client
If expecting, what is the due date?
What is the transportation need?
Type of health insurance:
Last Name
First Name
Middle Initial

Home Address (No P.O. Boxes or Route #s, please)

Street Address
Apt #
City
State
Zip Code
County

Other Client Information

Client's Phone #	- -
Alternate Phone # (friend, family member, neighbor)	- -
Email Address (if available)
Date of Birth	/ /
Social Security #	- -
Medicaid # (if applicable)
Race
Gender
Parent/Guardian/Emergency Contact Name
Relationship to Client
Guardian Phone #	- -
Does the client require a wheelchair lift?

Referrer Information

Referring Party's Name
Referring Party's Title
Referring Agency (if applicable)
Referring Party's Email Address
Referring Party's Phone #	- -

Trip Information

Date of Appointment	/ /
Appointment Time	:
Treating Facility/Agency Name
Treating Facility/Agency Street Address
Treating Facility/Agency Suite or Clinic #
Treating Facility/Agency City
Treating Facility/Agency Zip Code
Office Phone #	- -
Treating Facility/Agency Phone #	- -
Treating Facility/Agency Email Address
Doctor or Therapist Name
Number of Passengers

Before scheduling this appointment please make sure the client will follow through in keeping this appointment with Kid One. Held space cancelled at the last minute prevents other children from accessing our much needed service and may jeopardize the client's ability to access Kid One services.