ACCESS LYNX On-line Trip Request

ACCESS LYNX ADA and Medicaid customers may schedule their transportation using our Online Trip Request service (TD customers must call their trips in the day prior to service). To request a trip online, you must already be certified to use ACCESS LYNX.

Items in red are required.
Select Trip Type to Schedule	One-Way Two-Way (Round Trip)
(TIP: For trips where your final destination will be someplace besides your original origin, please submit multiple one-way trips.)
Applicant Information
Customer ID/SSN #
Salutation	Mr. Mrs. Ms. Miss Dr. Rev.
First Name
Middle Initial
Last Name
Primary Phone	() -
Alternate Phone	() -
Email Address
Trip Date & Time
Please indicate your request type.	One-time Trip Subscription
Trip Date/ Subscription Start Date	Wed, Feb 10, 2010 Thu, Feb 11, 2010 Fri, Feb 12, 2010 Sat, Feb 13, 2010 Sun, Feb 14, 2010 Mon, Feb 15, 2010 Tue, Feb 16, 2010

Select days this trip will take place.	Sun Mon Tue Wed Thu Fri Sat

Going Trip Time	Please pick me up by: Please drop me off by: 01 02 03 04 05 06 07 08 09 10 11 12 : 00 05 10 15 20 25 30 35 40 45 50 55 AM PM

Return Trip Time	Please pick me up by: Please drop me off by: 01 02 03 04 05 06 07 08 09 10 11 12 : 00 05 10 15 20 25 30 35 40 45 50 55 AM PM

Trip Locations
Pick-Up Location Name
Location Name Is The...	-- Please Select -- Apartment Complex Name Area Name Building Name Community Name Company Name Facility Name Property Name Subdivision Name
Street Number
Street Name
Apt / Suite / Bldg
City
State	Florida
ZIP Code
Location Phone	() -
Drop Off Location Name
Location Name Is The...	-- Please Select -- Apartment Complex Name Area Name Building Name Community Name Company Name Facility Name Property Name Subdivision Name
Street Number
Street Name
Apt / Suite / Bldg
City
State	Florida
ZIP Code
Location Phone	() -
Comments and/or Directions
Personal Care Attendants	0 1
Companions (ADA trips only)	0 1 2 3 4 5

Thank you for filling out the ACCESS LYNX Trip Request form. A trip confirmation will be emailed to you. If you do not receive a trip confirmation, please contact Customer Service at 407-423-TRIP (8747) before 4 p.m. of the day prior to your trip to verify that the information was received and a reservation was created.

All trips will be created using the information currently in your customer file. To update your customer file or verify that all information is correct, please contact us at 407-423-TRIP (8747).

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