Instructions: Drop down the Trip Number to view your Trips for today Select a Trip Number to see details Fill all the empty spaces and hit “Submit” to log in your trips. Manifest - Lord Trip Number: * Trip Date: MEMBER INFORMATION Appointment: Member Name: Member Phone: DOB: A2C ML Special Needs: Section Buttons TRIP INFORMATION Pickup Location: Pickup Location 2: Pickup County: Pharmacy Auth: Drop Off Location: Drop Off Location 2: Drop Off Phone: Section Buttons Comments: Scheduled Pickup Time: * This time must always be earlier than Appointment. If not, it means you are late and you must enter a reason in the notes. Arrived Time: * Select 0:00 for No Show or Trip Cancellation Pickup Time: * Drop Off Time: * RETURN TRIP Notify Time: ONLY FOR RETURN TRIPS: The time the Member calls back for their Return Trip Pickup Odometer * Drop Off Odometer * Mileage Section Buttons PROVIDER INFORMATION Provider: Driver Name: * Driver's License: Vehicle Name: Vehicle Vin: Section Buttons Trip Status: * Completed Cancellation No Show Left Card OtherOther Driver's Signature * Section Buttons Attendant's Name Attendant's Signature / Picture of Door (No Show): * In event of Trip Cancellation or No Show, upload driver signature here as well Cancelation / No show / Lateness Notes (If applicable): If you are human, leave this field blank. Submit Δ Sign GPS Back
