Facility Transportation Agreement Template: Rates, Booking, Privacy, and Payment

A handshake with a discharge planner is not a contract. When a hospital, nursing home, dialysis center, PACE program, or day center pays for its patients’ rides, both sides need the same answers in writing: who books, what each ride costs, what happens when a rider is not ready, and who pays when a van is late. Fill in this template, attach your rate schedule, and have a health care attorney review it before anyone signs.

How to use this template

1. Build Schedule A first. Copy your prices from the NEMT rate sheet template. Every charge the facility can see on an invoice has to appear there.
2. Ask for the facility’s paperwork before you draft. Get its insurance requirements, vendor forms, and any business associate agreement it uses. If the facility sends its own contract, use this template as a checklist: every Part below should have an answer in theirs.
3. Ask which rides the facility pays for. Some rides are the facility’s job and some go through the rider’s Medicaid ride program. Write the answer into Part 7 before you quote.
4. Fill in Parts 1 to 16. Write “Not offered” or “Does not apply” on any line that does not fit, so nothing is left to guesswork.
5. Read the rules under the template. They explain why the rates, billing, privacy, and compliance terms are written the way they are. For how to find and win this work, see NEMT facility contracts.
6. Have a lawyer review it before you send it. Contract law, insurance rules, and transportation licensing differ by state.
7. Send it to the facility’s contact. Ask whether its compliance office must approve the terms, and send them a copy too. Have your lawyer read any changes the facility makes.
8. Sign and calendar it. Put the term end date, the notice deadline, the rate review date, and each insurance renewal on your calendar.

The template

Transportation Services Agreement

Part 1: Parties and term

Item	Entry
Transportation company (legal name, called “the Company” below)
Company address and phone
Facility (legal name, called “the Facility” below)
Facility address, and the buildings or units this agreement covers
Effective date
First term ends (at least one year after the effective date)
Renewal	Renews for ___-month terms unless either side gives ___ days’ written notice

Part 2: Services

1. The Company provides non-emergency transportation for patients or residents the Facility books under this agreement. The Company does not provide medical care.
2. The Facility chooses the level of service for each rider, in writing, before the ride.
3. The Company provides only the services listed below and in Schedule A.

Level of service	Offered (yes or no)	Crew	Notes
Walking rider, with or without a cane or walker
Wheelchair, rider’s own chair
Wheelchair, Company’s chair
Bariatric wheelchair (over ___ pounds)
Stretcher, where state law allows
Facility staff member riding along

Service area and hours	Entry
Area served (cities, counties, or miles from the Facility)
Days and hours rides run
Holidays with no service

Part 3: Booking rides

Rule	Entry
How the Facility books (portal, email, phone, or form)
Staff who may book (names or titles)
Lead time for scheduled rides
Same-day requests: cutoff time, and how fast the Company answers
Will-call returns: how the Facility calls, and how soon the van arrives
Standing orders, such as dialysis three days a week: how they are set and changed
Company confirms each booking by
On time means pickup within ___ minutes of the scheduled time

Each booking gives only what the ride needs: the rider’s name, pickup and drop-off addresses and times, level of service, mobility equipment (and weight, for bariatric rides), whether a staff member rides along, a contact at each end, and trip instructions such as oxygen or a door code. The Facility does not send diagnoses or medical records.

Part 4: Pickup and drop-off

1. The Facility has the rider ready at the pickup time, with the items listed in the booking.
2. The driver waits up to ___ minutes at no charge. Waiting after that is billed at the Schedule A rate.
3. The driver hands each rider to the person named in the booking. A rider who cannot be left alone is never left without a handoff. If no one is there, the driver calls dispatch, and dispatch calls the Facility contact.
4. Drivers do not give medications or medical care. In an emergency during a ride, the driver calls 911 first, then dispatch, and dispatch calls the Facility.
5. The Facility decides whether a staff member rides along and says so in the booking. The Company never requires a rider to bring an attendant.
6. Riders’ own equipment, such as portable oxygen and walkers, travels secured.

Part 5: Cancellations and no-shows

Event	Charge to the Facility	Rule
Canceled ___ hours or more before pickup	None
Late cancellation
Rider not ready after the free wait, van leaves
Company more than ___ minutes late	Credit of
Company misses a booked ride	Credit of

These charges apply only to rides the Facility pays for. The Company never charges a rider, a rider’s family, or a Medicaid program for a late cancellation or a no-show. See the NEMT no-show policy template.

Part 6: Rates

1. Schedule A lists every rate. The Facility pays only rates on Schedule A.
2. Rates are set in advance for the term and are based on distance, time, or a fixed route. They are never set per patient carried, and never based on the volume or value of Medicare, Medicaid, or other federal health care program business between the parties.
3. A rate change takes effect only after ___ days’ written notice and a new Schedule A signed by both sides.
4. Fuel adjustment, if any: ____________________.

Part 7: Invoices and payment

Term	Entry
Invoice period (each ride, weekly, or monthly)
Invoices go to (name and email)
Each invoice lists, for every leg	Date, rider name or Facility ID, pickup and drop-off, level of service, miles, waiting, added services, and charge
Payment due	___ days after the invoice date
Payment method
Questions about a charge must be sent within	___ days, in writing, naming the ride
Charges not in question are paid by the due date	Yes
Late payment charge
Purchase order or authorization number
Rides the Facility pays for under this agreement
Rides booked through the rider’s Medicaid ride program instead

1. The Company bills each ride to one payer. Before booking, the Facility confirms that no other program, such as the rider’s Medicaid ride benefit, covers the ride.
2. The Company never bills Medicaid, a health plan, the rider, or the rider’s family for a ride the Facility pays for.
3. Rides for Facility patients that Medicaid covers are booked through the rider’s Medicaid ride program, not under this agreement.

The NEMT invoice template lists each leg the way Part 7 requires.

Part 8: Drivers and vehicles

Requirement	Standard	Proof on request
Driver’s license	Valid for the vehicle driven	Copy in driver file
Driving record	Checked at hire and every ___ months	Record in driver file
Background check	At hire, and ___	Result in driver file
Drug and alcohol testing		Policy and results
Training	Rider assistance, wheelchair securement, emergencies, privacy, and ___	Training records
Vehicle inspection	Before each shift	Inspection records
Vehicle maintenance	To the manufacturer’s recommendations	Maintenance log
Identification	Company name on vehicles, ID badge on drivers

Keep each driver’s proof in a driver file and each van’s in its inspection and maintenance records.

Part 9: Insurance

Coverage	Minimum limit	Facility named as additional insured (yes or no)
Commercial auto liability
General liability
Workers’ compensation	As state law requires	Does not apply
Employer’s liability
Other coverage the Facility requires

1. The Company sends a certificate of insurance before the first ride and at every renewal.
2. The Company tells the Facility within ___ days if any required policy is canceled or not renewed.

Part 10: Incidents and emergencies

1. The Company calls the Facility contact within ___ minutes of any accident, injury, fall, or problem at a handoff.
2. The Company sends a written incident report within ___ hours. See the NEMT incident report form.
3. Each side keeps incident records for ___ years.
4. Evacuation rides: the Facility’s emergency plan lists the Company as ___ (a primary or backup provider, or not included), with ___ vehicles available within ___ hours.

Part 11: Privacy of rider information

1. Each side keeps rider information confidential and uses it only to run, bill, and review rides under this agreement.
2. The Company keeps phones locked, keeps manifests out of sight, and shreds paper manifests. Texts to riders give only the pickup details.
3. The Company reports any lost phone or manifest, or any rider information sent to the wrong person, to the Facility within ___ days of finding it.
4. If the Facility requires a business associate agreement, both sides sign it as Schedule C. Where it conflicts with this Part, Schedule C controls.

Part 12: Compliance

1. Neither side offers, pays, asks for, or accepts anything of value for referrals of patients whose care Medicare, Medicaid, or another federal health care program pays for.
2. The Company’s prices to the Facility are the same as its prices to other customers with similar volume.
3. This agreement is not exclusive. Neither side must refer patients to the other, or buy any other service from the other, to get the rates in Schedule A.
4. Drivers, dispatchers, and anyone arranging rides are not paid per patient carried.
5. No one markets health care items or services to riders during a ride.
6. Each side checks its owners, staff, and contractors against the OIG List of Excluded Individuals and Entities before signing and every month after. Each side tells the other in writing within ___ days of learning that any of them is excluded.

Part 13: Records and audits

1. The Company keeps a record of every leg, with times, miles, and the driver’s name, for ___ years. See the NEMT trip log template.
2. The Company gives the Facility copies of the records behind any invoice within ___ business days of a written request.

Part 14: Ending the agreement

How it ends	Notice
Either side, for any reason	___ days’ written notice
For a problem the other side has not fixed	Written notice, then ___ days to fix it
At once	Insurance lapse, loss of a required license, or exclusion from a federal health care program

After the agreement ends, the Company completes or hands back rides already booked for the next ___ days, sends a final invoice within ___ days, and returns or destroys the Facility’s rider information.

Part 15: General terms

1. The Company runs its own business. Its drivers are its own employees or contractors, not the Facility’s.
2. Each side is responsible for claims caused by its own staff’s negligence or its own breach of this agreement.
3. Neither side assigns this agreement without the other’s written consent. The Company gives ___ days’ written notice before a sale of the Company or a change in who controls it.
4. Notices go in writing to the contacts in Schedule B.
5. Changes are valid only in writing, signed by both sides.
6. The law of the state of ____________ governs this agreement.
7. This agreement and its schedules are the whole agreement.
8. Electronic signatures and copies count as originals.

Part 16: Signatures

	Company	Facility
Signature
Printed name
Title
Date

Schedule A: Rates

Effective date of this schedule: ____________. Replaces the schedule dated: ____________.

Level of service	Base fee per one-way ride	Each loaded mile	Waiting, each 15 minutes after the free wait	By the hour (minimum hours)	By the route (per run)
Walking rider
Wheelchair
Bariatric wheelchair
Stretcher

Added service	Price	Charged per
Second crew member
Weekend, holiday, or after-hours ride
Same-day booking
Tolls and parking	At cost, with receipt	Ride

Schedule B: Contacts

Role	Company	Facility
Day-to-day contact and phone
After-hours or on-call phone
Billing contact and email
Privacy contact
Address for legal notices

Schedule C: Business associate agreement (only if the Facility requires one)

Check that the Facility’s agreement covers each term HHS lists for business associate contracts, and write down where.

Term	Section in the Facility’s agreement
Uses and disclosures of rider information the Company may make
No other use or disclosure, except as the law requires
Safeguards, including the HIPAA Security Rule for electronic information
Reporting of improper uses, security incidents, and breaches, and the deadline for each
Optional: who sends breach notices to riders and to HHS, if the Facility wants the Company to
Helping the Facility answer a rider’s request for access, amendment, or an accounting
Records open to HHS
Return or destruction of rider information when the agreement ends
Same terms for any subcontractor that handles rider information
The Facility’s right to end the agreement for a material violation

How to price facility rides without kickback risk

When a facility pays for rides so its patients ride free, a federal anti-kickback safe harbor protects those free or discounted local rides only when all of its conditions are met (42 CFR 1001.952(bb)). Some conditions are yours to meet, and some belong to the facility’s own ride policy:

Safe harbor condition	Where it is covered
Drivers and anyone arranging rides are not paid per patient transported	Parts 6 and 12
No marketing of health care items or services during the ride, or at any time by the drivers	Part 12
Not air, luxury, or ambulance-level transportation	Part 2
The facility bears the cost and does not shift it to a federal program, another payer, or the rider	Part 7
The facility offers rides under a set policy it applies uniformly, not based on the volume or value of federal program business, and does not publicly advertise them	The Facility’s own policy
Rides are for established patients, to get medically necessary care	The Facility’s own policy
Rides stay within 25 miles, or 75 miles for a rider in a rural area, except a ride home after an inpatient stay or at least 24 hours of observation	The Facility’s own policy

When OIG created the safe harbor, it said a facility that hires a transportation company cannot pay it per patient transported, but may pay based on the total distance the vehicle travels (81 FR 88387, December 7, 2016). It also said rides in vehicles equipped for wheelchairs, other than ambulances, are protected when the other conditions are met (81 FR 88386). That is why Schedule A prices by the mile, the hour, or the route.

No discounts tied to referrals

The federal anti-kickback statute makes it a felony to knowingly and willfully offer, pay, ask for, or receive anything of value in return for referrals of federal health care program business. A conviction carries a fine of up to $100,000, up to 10 years in prison, or both (42 U.S.C. 1320a-7b(b)). OIG says remuneration includes anything of value and can take many forms besides cash, and that the law covers both the side that pays and the side that receives.

OIG’s compliance guidance for nursing facilities (November 20, 2024) warns against swapping. That is a low price on business the facility pays for, given in exchange for referrals of other business the supplier bills to a federal program. OIG says swapping is not protected by the discount safe harbor, whatever the size of the discount, and names ambulance providers among the arrangements prone to it. It lists these as suspect:

• Prices below cost.
• Prices below those offered to customers with similar volume but no federal program referrals.
• Discounts coupled with exclusive provider agreements, or with agreements to refer other business.

Part 12 answers each one: one price for customers of similar volume, and no exclusivity or referral promise tied to the rates. See anti-kickback rules for NEMT.

Set the pay method in advance for at least a year

When two businesses that can refer federal program business to each other sign a services contract, the personal services safe harbor (42 CFR 1001.952(d)) protects the payments only if:

1. The agreement is in writing and signed by both sides.
2. It covers all the services provided during the term and names them.
3. The term is at least one year.
4. The method for setting pay is fixed in advance, consistent with fair market value, and does not take into account the volume or value of referrals or other federal program business between the parties.
5. The services do not promote any arrangement or activity that breaks state or federal law.
6. The services are no more than a commercially reasonable business purpose needs.

Part 1 sets a term of at least a year, and Schedule A fixes the pay method before the first ride.

Which rides the facility pays for

A Medicaid provider must accept the program’s payment, plus any cost sharing the state plan sets, as payment in full (42 CFR 447.15). CMS adds that states and providers may not charge a Medicaid member for no-shows (SMD 23-006, September 28, 2023). So each ride goes to one payer, and states decide which facility rides are the facility’s job:

State	Rule
New York (manual effective August 25, 2023)	Intermediate care facilities, supervised community residences, and supervised and supportive individualized residential alternatives certified by the Office for People With Developmental Disabilities (OPWDD) must provide or pay for residents’ rides to medical and clinical appointments at no added cost to Medicaid. OPWDD day treatment, day habilitation, community habilitation, prevocational, and employment programs pay for rides to and from the program out of their day program payment. Adult day health care programs that contract for rides pay the transportation company directly, and Medicaid will not approve those rides. A nursing home may not charge Medicaid residents or families when its staff member rides along, and may not use a higher level of transport to fit that staff member.
Texas (managed care NEMT handbook, UMCM 16.4, version 2.0.1, effective August 1, 2021)	NEMT does not cover rides to or from a nursing facility, except for dialysis or a discharge home. It also does not cover rides to or from a Day Activity and Health Services facility, an assisted living facility, or a state institution, or rides tied to a Medicaid service whose rate already includes transportation.

Other states draw these lines differently, so check your state’s Medicaid transportation manual or your broker. Then ask each facility which rides it pays for and which go through the rider’s Medicaid ride program, and write both answers into Part 7. For Medicaid rides, see how to bill Medicaid for NEMT.

Rider privacy and business associate agreements

HIPAA defines a business associate as a company that creates, receives, maintains, or sends protected health information on behalf of a covered entity, such as a hospital. The definition leaves out a health care provider receiving information from a covered entity for a patient’s treatment (45 CFR 160.103). Whether that exception fits your rides is a question to settle with the facility’s privacy officer and your lawyer. See HIPAA for NEMT providers.

If you sign a business associate agreement, federal rules decide what it must say (45 CFR 164.504(e)), and Schedule C lists those terms. HHS publishes sample provisions. It says using them is not required for compliance and does not replace a lawyer.

A business associate must report a breach of unsecured information to the covered entity without unreasonable delay and within 60 calendar days of discovering it (45 CFR 164.410). HHS’s sample notes that the parties may agree to a stricter deadline, and may decide whether the business associate sends breach notices for the covered entity. Read the facility’s numbers before you sign. For the rest of the agreement, see business associate agreement.

The booking rule in Part 3 applies HIPAA’s minimum necessary standard. A covered entity or business associate must make reasonable efforts to limit the information it uses, sends, or asks for to what the purpose needs (45 CFR 164.502(b)). The standard has exceptions, such as disclosures to a health care provider for treatment, but a ride never needs a diagnosis. It needs addresses, times, and mobility needs.

Exclusion checks on both sides

OIG may impose civil money penalties on anyone who contracts with a person or company they know, or should know, is excluded from federal health care programs, for services those programs pay for (42 CFR 1003.200(b)(4)). OIG says this duty means screening all current and prospective employees and contractors against its exclusion list. It generally updates the list by the middle of each month with the prior month’s actions. Part 12 makes both sides check. See OIG exclusion list.

What PACE programs, nursing homes, and federal facilities must put in writing

• PACE programs. Each contract must be in writing and name the contractor, the services, the payment rate and method, and the start and end dates, with how the contract is extended, renegotiated, and ended (42 CFR 460.70(d)). The contractor must agree to give only services the care team authorizes, accept PACE payment as payment in full without billing participants, CMS, the state, or private insurers, hold CMS, the state, and participants harmless if the program does not pay, not assign the contract without written approval, and send the reports the program requires. The program must train contracted transportation staff in participants’ special needs and emergencies, make sure contracted vehicles are maintained to the manufacturer’s recommendations and can communicate with the PACE center, and tell drivers about relevant changes in a participant’s care plan (42 CFR 460.76). Add those terms to Parts 2, 7, 8, and 13.
• Nursing homes. When a nursing home has an outside company furnish a service it must provide, the written agreement must say the home is responsible for the service meeting professional standards and for its timeliness (42 CFR 483.70(f)). Make the on-time rule in Part 3 one you can meet every day.
• Federal facilities, such as VA medical centers. Each contract states the insurance it requires. The FAR’s standard minimums, which cost-reimbursement contracts ordinarily require and fixed-price contracts use for work on a government installation, are, as of September 2026: $200,000 per person and $500,000 per occurrence for auto bodily injury, $20,000 per occurrence for auto property damage, $500,000 per occurrence of general liability for bodily injury, and $100,000 of employer’s liability (48 CFR 28.307-2). Unless the contract sets a date, payment is generally due 30 days after the agency receives a proper invoice (5 CFR 1315.4). In most cases, a late payment earns interest at the Prompt Payment rate, 4.75 percent for July 1 through December 31, 2026. VA contracts that include clause 852.232-72 accept invoices only through VA’s electronic invoicing system or an X12 EDI system, never by email, fax, or scan, unless the contracting officer directs you to mail them. See VA transportation contracts and the NEMT invoice template.

Riders who use wheelchairs

DOT’s ADA rules bar special charges on riders with disabilities, including wheelchair users, for services the rules require or that are needed to accommodate them. They also bar requiring a rider with a disability to bring an attendant (49 CFR 37.5). Part 4 leaves the choice of a staff escort with the Facility and never makes one a condition of the ride. Before Schedule A prices a wheelchair ride higher than a walking ride, read the wheelchair section of the rate sheet template and have your lawyer review the difference.