Request Behavioral Health Transportation | DHA Secured Transportation

Requester Info

Route & Schedule

Individual & Notes

Request for Transportation

Step 1: Requester & Facility Details

Please enter your contact information and facility or organization name.

Organization / Facility Name *

Requesting Person Name *

Job Title / Role

Phone Number *

Email Address *

Required fields marked with *

Step 2: Transportation & Routing Details

Specify pickup location, receiving facility, requested timing, and transport classification.

Trip Direction

One-Way Trip Round Trip

Pickup Location *

Destination Facility *

Requested Date *

Requested Time *

Transport Classification *

Current Location Type *

Step 3: Individual Information & Dispatch Notes

Provide non-sensitive individual reference details and any special handling or mobility notes.

Age Group *

Date of Birth (DOB) *

Medicaid ID / Member # (Optional)

Relevant Transportation Notes & Special Instructions

Emergency Medical Disclaimer: If the individual is experiencing an immediate life-threatening medical emergency requiring active medical monitoring or paramedic life support, please dial 911 immediately.

Security Verification *

Transport Request Dispatched!

Your dispatch details have been sent directly to DHA Secured Transportation (Dhatransportation@outlook.com). Our coordination team will follow up immediately.

Trip Summary Details

Dispatched

Pickup Location

—

Destination Facility

—

Requested Schedule —

Transport Classification —

Facility / Organization —

Requester & Contact —

Individual DOB & Age —

Medicaid ID / Member # —

Special Instructions / Notes

—

24/7 Dispatch Coordination Support (720) 276-2551

Colorado Authorized Secure Transit Provider • Call for Immediate Updates