BCCOAFriendship Center

Friendship Center

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Transportation Application

The Transportation Disadvantaged Program was established to provide transportation services to the elderly, disabled, economically disadvantaged, children at risk and to individuals who have no other forms of transportation. It is our goal to provide citizens with safe, reliable, convenient, affordable and cost efficient public transportation. For more information, please call BCCOA transportation department at 904-259-9315 ext. 239.

Section 1 - Personal Information

"Sections Highlighted In Red Are Required Fields"

Section 2 - Household Member Infomation

Household Member & Total Household Income:

Section 3 - Availability of Transportation

What type of vehicle do you own?
Is there a reason why you cannot drive your car?
Does any other member of your household own a vehicle?
Could anyone in your household, family or friends transport you to your appointments?
How are you currently being transported?
Are you aware you are required to pay a co-payment for this program?
If yes please give us the reason
Will the transportation be temporary or permanent?
Do you receive VA benefits for transportaion?

Section 4 - Information About Recurring Medical Appointments

Section 5 - Special Needs

Section 6 - Certification and Acknowledgment

I understand and affirm that the information provided in this application for CTD Medicaid Non-Emergency Transportation (NET) services is true and correct, to the best of my knowledge, and will be kept confidential and shared only with medical and transportation professionals involved in evaluating and determining my needs for transportation to and from medical appointments. I understand that providing false or misleading information, or making fraudulent claims, or making false statements on befall of others constitutes a felony under the lows of the State of Florida.
Submit your Application
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Baker County Council on Aging Transportation Department 9264 Buck Starling Road Macclenny, Florida 32040