NEMT Daily Manifest Template: A Driver's Day Sheet, Leg by Leg

A daily manifest is the driver’s plan for the day: every trip leg in order, with the times, addresses, and instructions needed to run it. Brokers send trip details through their portals. A clean one-page run keeps the driver on schedule, and it gives dispatch the record it needs to close out the day. This template has two halves: what dispatch fills in the afternoon before, and what the driver fills in at each stop.

How to use this template

1. Build it the afternoon before. Once trips are accepted and riders confirmed, put each driver’s legs in pickup order. NEMT scheduling covers building the runs, and NEMT dispatch covers the rest of the dispatcher’s day.
2. Check the broker portal for loose trips. MTM Health’s Rhode Island handbook (July 1, 2026) says some trips arrive “Unassigned,” and your dispatcher must move each one onto a driver’s manifest so none is missed.
3. Check credentials before you assign. The same handbook asks for renewed company, driver, and vehicle credentials at least 10 business days before the old ones expire. If a renewal is not in at least 5 days before, trips tied to that company, driver, or vehicle can come off the manifest on the expiration date.
4. Make one manifest per driver, per vehicle, per day. If a driver switches vans mid-shift, start a new manifest for the second van, so every leg ties to the vehicle that ran it.
5. Copy each leg exactly. Take the trip ID, times, addresses, level of service, and instructions straight from the broker’s trip. MTM Health’s Virginia handbook (approved August 10, 2026) makes providers responsible for reviewing and following all manifest information.
6. Number every leg. Parts 2 and 3 share the same row numbers. A round trip is two legs, and each gets its own line. See trip leg.
7. Keep regular riders with the same driver when you can. Virginia’s handbook asks for a best-faith effort to use the same driver on standing-order trips, and a note when another driver has to take them.
8. Print Parts 2 and 3 with the page turned sideways. The wide tables fit, and the driver gets room to write.
9. Hand it over at check-in. Give the driver the manifest with the morning vehicle inspection checklist, and go over any will-calls and new riders.
10. Collect it at the end of the shift. Match it against the trip logs and the broker portal before you bill.

Here is how one round trip looks in Part 2. It takes two lines, and the leg numbers follow pickup order, so the return sits wherever it falls in the day.

#	Pickup time or window	Trip ID, leg	Rider, phone	Service level, equipment	Pick up at	Drop off at, appt. time	Notes
3	8:45 to 9:15 a.m.	Broker’s ID, A	Full name, cell	Wheelchair van, door to door, own chair	Home address, apartment number	Dialysis center, 10:00 a.m.	Ramp at side door. Center’s phone.
7	Will-call	Same ID, B	Same rider	Same	Dialysis center	Home	Rider calls when done. Arrive within the broker’s will-call time.

The template

Part 1: Driver and vehicle

Field	Entry
Company name
Date of service
Driver’s name
Attendant’s name, if any
Vehicle number and plate
Vehicle type and seating (seats, wheelchair spots, stretcher)
Shift start and end
Odometer at start of shift
Odometer at end of shift
Dispatch phone
Backup phone if dispatch does not answer
Brokers and payers on today’s run
Page ___ of ___

Part 2: Today’s legs in order (dispatch fills in)

Write “Will-call” in the pickup column for a return with no set time.

#	Pickup time or window	Trip ID, leg	Rider, phone	Service level, equipment	Pick up at	Drop off at, appt. time	Notes
1
2
3
4
5
6
7
8
9
10

What goes in the columns:

• Rider: full name and phone, plus the Medicaid ID where the broker or state asks for it. Georgia’s vehicle manifest includes it.
• Service level: the mode and the level of assistance the broker approved, such as curb to curb, door to door, or hand to hand, plus any wheelchair, walker, or other equipment the rider brings.
• Notes: an escort or attendant riding along, the rider’s weight with the mobility device when the broker lists it, the entrance, gate code, or apartment, the rider’s language, any authorized wait, and the facility’s phone number.

Part 3: What happened at each stop (driver fills in)

Write each time as it happens, in pen.

#	Arrived at pickup	Left pickup	Odometer at pickup	Arrived at drop-off	Odometer at drop-off	Result	Driver initials
1
2
3
4
5
6
7
8
9
10

Result: completed, no-show, canceled at the door, or turned back to dispatch.

Part 4: Changes and calls during the day

Give an added trip the next leg number and fill its rows in Parts 2 and 3.

Time	Leg #	What changed (added trip, will-call called, new address, late, no-show, incident)	Who approved it or was told	Broker told at

Get the broker’s approval before any new address or different vehicle type, and follow your broker’s rule for moving a pickup or appointment time. Write who approved each change in this table.

Part 5: End of shift

Check	Done
Every leg has a result in Part 3
A trip log is filled for every completed leg
Every no-show and late arrival is reported to the broker
Any incident is written up
Manifest returned to dispatch (time)
Driver signature
Dispatcher signature

What a manifest needs to show

Each broker sets its own fields. Three published lists show the common core, and the template above has room for the fields they share. Signatures go on the trip log.

Field	MTM Health, Virginia (August 10, 2026)	Texas Medicaid health plans (UMCM 16.4)	Georgia Medicaid (July 1, 2026)
Trip ID for each leg	Yes, for billing	Yes, for each leg	Not listed
Rider’s name	Full name	Yes	Yes, with Medicaid number
Rider’s phone	Yes	Yes	Not listed
Pickup address and time	Yes	Address	Pickup point and scheduled time
Destination	Address, doctor or facility name and phone	Address, facility name and phone	Yes
Appointment time	Yes	Not listed	Yes, if there is one
Mode and level of assistance	Yes	Mode, wheelchair need, mobility devices	Not listed
Escort or attendant	Whether one rides, or you must supply one	Attendant’s signature	Escort’s name and relationship, and any broker attendant
Rider’s weight with mobility device	Yes	Not listed	Not listed
Special needs or instructions	Yes	Yes	Not listed
Driver and vehicle	Not listed	Not listed	Provider, vehicle number, driver’s name
Actual times and odometer readings	Not listed	Not listed	Yes, filled in by the driver

How the three programs use the manifest differs:

• Virginia. MTM Health puts its manifests in the MTM Link portal and sends them through a feed to routing software. They are meant to give the driver everything needed to run each trip at the authorized level of service and assistance.
• Texas. Health plans or their subcontractors must send the trip manifest by secure data transmission, such as SSL encryption. The handbook lists the member’s signature, plus a parent’s or attendant’s when one rides, and lets the plan verify the ride with a digital signature or GPS at pickup and drop-off.
• Georgia. Each vehicle driver completes a vehicle manifest every day with 17 items. They include the actual arrival and departure times at the pickup, the actual return time from the drop-off point, and odometer readings at pickup and drop-off. The broker must keep them as service records.

Most changes need the broker’s approval. CareOregon requires it for a new pickup time, appointment time, or address, and for a different vehicle type unless the vehicle you send still meets the rider’s needs, such as a wheelchair van with regular seats for a rider booked in a sedan. MTM Health’s Rhode Island handbook says drivers go only to the addresses on the manifest, and MTM verifies a new address and updates the manifest before the trip goes ahead. The same handbook’s portal guide lets you update a scheduled pickup time yourself, and says to call the rider if they have not been told.

Timing rules to write on each leg

Put the payer’s rule next to the time, so the driver never has to guess.

Program	On-time pickup	Wait before a no-show	Will-call return	Hospital discharge	Extra ride time on shared rides
MTM Health, Virginia (August 10, 2026)	15 minutes before to 15 minutes after the scheduled pickup, and drop-off no later than the appointment	Through the pickup window, then call or text the rider	Within 45 minutes of the call	Within 3 hours of the call	45 minutes over the average direct trip
MTM Health, Rhode Island (July 1, 2026)	Within 15 minutes of the stated time	Not required past 10 minutes after the scheduled pickup. Call or text the rider before leaving	Within 45 minutes of the call	Not listed	45 minutes over the average direct trip
Georgia Medicaid (July 1, 2026)	Within 15 minutes of the stated time	Not required past 10 minutes after the scheduled pickup	Within 1 hour of the call	Within 3 hours of the request	45 minutes over the average direct trip
Texas Medicaid health plans (UMCM 16.4)	Scheduled to arrive 15 minutes to 1 hour before the appointment	At least 10 minutes after the scheduled pickup	Within 1 hour of the request	Up to 3 hours	1 hour over the average direct trip
CareOregon (February 2024)	No pickup before the scheduled time or window unless the rider chooses to go early	At least 15 minutes after the scheduled pickup, then tell dispatch	Return rides: try to pick up within 15 minutes of the facility closing	Not listed	Not listed

In Virginia, Rhode Island, Georgia, and the CareOregon network, a rider never has to board before the scheduled pickup time, even when the van is early. The full definition is in pickup window, and returns are covered in will-call trip. CareOregon also bars drop-offs more than 15 minutes before a facility opens, unless the rider asks. Texas plans must schedule a first or last appointment of the day so the rider is not dropped off more than 15 minutes before the office opens or picked up more than 15 minutes after it closes. Write opening and closing times in the Notes column for those legs.

Keep rider information private on the manifest

A manifest lists riders’ names, phone numbers, home addresses, and where they get care. CareOregon’s manual counts names, phone numbers, and street addresses among the protected information its providers must handle securely. HIPAA for NEMT providers explains when these rules reach your company.

Two federal rules shape what goes on the page:

• Minimum necessary. Covered entities and business associates must make reasonable efforts to limit health information to the minimum needed for the purpose (45 CFR 164.502(b)). A covered entity must also decide which staff need which information, and limit their access to that (45 CFR 164.514(d)). For a manifest, that means each driver gets only their own legs.
• Safeguards. A covered entity must reasonably safeguard health information, including to limit incidental disclosures (45 CFR 164.530(c)).

Broker manuals turn those rules into driver habits. MTM Health’s Rhode Island handbook says member information should not be visible to other passengers, and drivers must not discuss it with anyone outside the member’s care, including other riders in the van. CareOregon’s manual says drivers leave no papers or devices with member information where others can see them, avoid reading it where passengers can see, and do not discuss it by phone or radio in front of others.

Put those habits into your routine:

1. One manifest per driver. Never leave a full-fleet sheet in a van.
2. Leave out diagnoses and the reason for the visit. Write only what the driver needs to run the leg.
3. Keep paper in a closed folder, never on the dashboard or the seat.
4. Lock the phone with a passcode, and read the manifest only while parked. Virginia’s handbook bars phone use or texting while the vehicle is moving.
5. Never text a photo of a manifest. Send changes through the broker portal or your dispatch system. CareOregon requires a secure email portal for any email with member information.
6. Check who is calling. CareOregon’s manual bars dispatchers from giving trip details to a caller until they confirm the caller is the rider, the rider’s caregiver or representative, or the rider’s health care provider.
7. Report a lost manifest to dispatch right away. CareOregon wants a suspected breach reported to the brokerage immediately, and no more than 24 hours later.

A manifest is not proof of the ride

A manifest shows the plan. The trip record shows what happened. New York’s manual (effective August 25, 2023) says a driver or vehicle manifest or dispatch sheet is not acceptable as the only evidence of a trip, though it can supplement the required records. For every leg, New York requires the rider’s name and Medicaid ID, the date, the origin and pickup time, the destination and drop-off time, the plate number, the driver’s license number, and the driver’s printed name, signature, and statement that the trip was completed.

Georgia goes the other way and makes the completed vehicle manifest one of the records its broker must keep. Part 3 of this template has columns for Georgia’s actual pickup times and odometer readings. Wherever your state or broker asks for a signed record of each leg, fill a trip log too. NEMT trip documentation lists what each record needs.

Keep the completed manifest with the trip logs for the longest period that applies to you. New York requires trip records for six years after the date of payment. CareOregon requires providers to store the trip data the brokerage sends them and keep trip records for at least six years after the service. MTM Health’s standard agreement, in the January 1, 2023 version Pennsylvania posts, requires full and complete records for 10 years. It also lets MTM and government officials inspect trip and log sheets during business hours, unannounced.