Lord's Manifest | Just In Time Transportation Services

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:

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TRIP INFORMATION

Pickup Location:

Pickup Location 2:

Pickup County:

Pharmacy Auth:

Drop Off Location:

Drop Off Location 2:

Drop Off Phone:

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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

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PROVIDER INFORMATION

Provider:

Driver Name:

Driver's License:

Vehicle Name:

Vehicle Vin:

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Trip Status:

Driver's Signature

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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.

Lord’s Manifest

Instructions:

MEMBER INFORMATION

TRIP INFORMATION

PROVIDER INFORMATION

Sign

GPS

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