TripCare Facility Registration Form

Modivcare offers TripCare, a secured web portal, designed to allow medical facilities to request trips and standing orders from Modivcare electronically. Modivcare will provide two (or more upon request) administrative logins to TripCare for each medical facility. The medical facility admin users are required to manage access to TripCare for all other users at their facility. To use TripCare, you must register via this EDI form. Modivcare will share the TripCare user login information with the user and explain the next steps for training. Once your administrative users are setup, those users can create additional logins for other employees at your facility as needed.

Date Requested*

Facility Name*

Physical Street Address*

City*

State*

Select

Zip Code*

Facility Phone Number*

Numbers only please

Phone

Fax Number

Numbers only please

Medicaid Provider Number or NPI*

Permission level requested*

Select

User's name*

User's Email*

This must be a company email address. The system will not allow an account with a free domain that does not match the facility name.

User's Job Title*

By digitally checking this box, I hereby agree:*

I will abide by all federal and state regulations pertaining to protected health information (PHI) including the Health Insurance Portability and Accountability Act (HIPAA)
I will only provide portal access to employees at my medical facility that have a need to request or review transportation requests.
I will remove terminated users or users who no longer need access to the portal immediately.
Modivcare may remove portal access for me or my medical facility at any time, with or without cause.
I will use the system in accordance with Modivcare's documented instructions.
I will not share my user ID or password with another user.
I understand that the intentional entry of invalid or false information is unlawful and may have significant adverse legal repercussions.
I will notify Modivcare immediately if I believe a security incident has occurred.

User Signature*

You may type your name into this form in lieu of a hand written signature

Send me a copy of my responses

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