NEMT Invoice Template for Private-Pay and Facility Rides, Leg by Leg

An invoice is how a family, a senior living community, or a hospital checks what you did before it pays. If every leg is on its own line, with the same date, miles, and times as your trip log, most questions answer themselves and payment comes sooner. This template is for rides paid by a rider, a family, or a facility. Medicaid and broker trips are billed on a claim or through the broker’s own system instead.

How to use this template

1. Price from your rate sheet. Every charge on the invoice should match a line on your dated NEMT rate sheet or on Schedule A of a signed facility transportation agreement.
2. Copy each leg from the trip log. Take the date, times, and loaded miles from the trip log, so the invoice and the log always match.
3. Write one line per leg. A leg is one one-way ride. A round trip to dialysis is two legs, and a stop at the pharmacy on the way home is an added service on the return leg.
4. Send one invoice per payer per billing period. A private rider may pay after each ride. A facility gets one invoice for the period its agreement sets, such as a week or a month.
5. Number invoices in order. Never reuse or skip a number, and write the number on every payment you record.
6. Fill in only what the payer needs. The table after the template shows what goes on each kind of invoice.
7. Record each payment and hand over a receipt. Fill in Part 9 when you are paid, keep a copy, and log it in your payment log.

For Medicaid trips, see CMS-1500 for NEMT and how to bill Medicaid for NEMT.

The template

Part 1: From

Line	Entry
Company legal name, and trade name if different
Address
Phone and email for billing questions
Taxpayer ID (only for payers that ask for it)
NPI (only for payers that ask for it)

Part 2: Invoice details

Line	Entry
Invoice number
Invoice date
Rides from (date) through (date)
Payment due date
Purchase order, contract, or authorization number
Rate sheet or Schedule A used (effective date)
Account number

Part 3: Bill to

Line	Entry
Payer (rider, family member, or facility)
Attention (billing contact)
Address or email the payer chose for invoices
Rider, if the payer is not the rider (name, or the facility’s ID for the rider)
Payer’s relationship to the rider (family payers only)

Part 4: Rides, one row per leg

Leg	Date	Rider (name or facility ID)	From	To	Level of service	Picked up	Dropped off
1
2
3
4
5
6

Part 5: Charges for each leg

Leg	Base fee	Loaded miles × rate	Waiting minutes billed × rate	Added services (name and price)	Leg total
1
2
3
4
5
6

Loaded miles are the miles driven with the rider aboard, from pickup to drop-off, measured by: ____________________. The drive to reach the rider is priced into the base fee, not listed as miles. See loaded miles.

Part 6: Other charges and credits

Item	Leg or date	Amount
Tolls and parking (receipts attached)
Late cancellation or no-show fee, as agreed in writing (never for a Medicaid ride)
Discount (write the reason)
Credit for a late or missed ride
Deposit applied

Part 7: Totals

Line	Amount
Total of all legs (Part 5)
Other charges (Part 6)
Credits and discounts (Part 6)
Payments already received (date and method)
Previous balance
Amount due
Due date

Part 8: How to pay

Method	Details
Check	Payable to ____________, mailed to ____________
Card	Call ____________ or pay at ____________
Bank transfer (facilities)	Details given by phone from our billing contact
Late payment charge	Only as set in a signed agreement: ____________
Questions about a charge	Call or email ____________ within ___ days of the invoice date, naming the leg

Part 9: Paid receipt (fill in when paid)

Line	Entry
Paid in full on (date)
Amount paid
Method (card ending, check number, or cash)
Received by
Service	Medical transportation on the dates listed above

Part 10: Print at the bottom of every invoice

• Prices are from our rate sheet or facility agreement dated ____________.
• Each leg is one one-way ride. A round trip is two legs.
• This invoice is for rides paid by the rider, a family member, or a facility. We do not bill Medicaid members for rides Medicaid covers.
• We never list diagnoses or the reason for a visit. Call us if you need a record for your health plan or tax preparer.

What goes on the invoice and what stays off

Detail	Invoice to a rider or family	Invoice to a facility
Rider’s name	Yes	Name, or the ID the facility uses for the rider
Date and pickup and drop-off times	Yes	Yes
From and to	Street address, or “home” and “medical office”	Building or unit, and the destination address
Level of service	Yes	Yes
Loaded miles, waiting, added services	Yes	Yes
Diagnosis or reason for the visit	Never	Never
Medicaid ID, Social Security number, date of birth	Never	Only if the signed agreement requires one

The privacy rules behind that table:

• Keep payment disclosures to the minimum necessary. Billing and collecting are payment activities under HIPAA (45 CFR 164.501). If your company is a covered entity or a business associate, it must make reasonable efforts to limit what it discloses for payment to the minimum necessary (45 CFR 164.502(b)), with policies for routine disclosures such as invoices (45 CFR 164.514(d)). The rule does not apply to disclosures to the rider themselves.
• Family payers see only their part. A covered entity may share with a family member or friend only the information directly relevant to their involvement in the rider’s care or payment for it. If the rider is present and able to decide, you need the rider’s agreement, a chance for the rider to object that they do not take, or a reasonable judgment from the circumstances that they do not object (45 CFR 164.510(b)).
• Send invoices where the rider asks. A covered health care provider must accommodate reasonable requests to send communications by another means or to another address, such as email instead of a home mailbox. It may ask for the request in writing, but not for the reason (45 CFR 164.522(b)).

Even if HIPAA does not reach your company, a facility agreement or broker contract may require the same care. See HIPAA for NEMT providers and minimum necessary.

Billing rules every invoice has to follow

Never invoice a Medicaid member for a covered ride

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 says states and providers may not charge a Medicaid member for no-shows (SMD 23-006, September 28, 2023). Texas Medicaid’s provider manual (sections 1.7.12 and 1.7.12.1, September 2026) shows how one state sets the conditions for billing a Medicaid client privately:

1. You tell the client, at the time of service, that you accepted them as a private pay patient who pays for all services received.
2. You get the client’s signed, written notice of that status. Without it, you cannot seek payment. The manual points to a Private Pay Agreement form on the website of the Texas Medicaid & Healthcare Partnership (TMHP).
3. If you accepted the client as private pay while their Medicaid eligibility was pending and they become eligible retroactively, you refund what they paid and file Medicaid claims for the rides.
4. A provider that bills a client outside these conditions may be excluded from Texas Medicaid.

Other states and broker contracts set their own rules, so read your state manual and each broker agreement before you bill any member. See private pay NEMT.

Charge what your rate sheet says

Your private prices can matter to Medicaid. In Texas, a provider that sends a signed claim to TMHP certifies that its charges are usual and customary and not higher than the fees charged to private-pay patients. It also certifies that any reduced, discounted, free, or special fee advertised to the public is offered to Texas Medicaid clients too (provider manual, section 1.7.11, September 2026). Your invoices are the record of what you actually charged, so bill from the dated rate sheet and write the reason for every discount in Part 6.

Bill one payer for each ride

A ride a facility pays for is never also billed to Medicaid, a health plan, or the rider. The facility transportation agreement template explains the rules and has the facility confirm, before booking, that no other program covers the ride.

Invoices to federal facilities

Federal agencies, such as VA medical centers, pay under the Prompt Payment rules. A proper invoice has these items (5 CFR 1315.9(b)):

Item	Where it goes on this template
Your company name	Part 1
Invoice date and invoice number	Part 2
Contract number or other authorization	Part 2
Description, price, and quantity of the services	Parts 4 and 5
Payment terms	Parts 2 and 8
Taxpayer ID and banking information, unless the agency’s procedures say otherwise	Part 1, and the agency’s payment setup
Contact name, title, and phone	Part 1
Anything else the contract requires	Attach it

VA contracts that include clause 852.232-72 (November 2018) require every payment request in electronic form, through VA’s Electronic Invoice Presentment and Payment System or an X12 EDI system. Email, fax, and scanned invoices are not accepted, and a ride paid with a government purchase card needs no separate electronic invoice (48 CFR 852.232-72). The contract gives the system’s current web address. Mail invoices only if the contracting officer tells you to.

An agency that finds an invoice improper must return it within 7 days of receiving it, with every defect listed (5 CFR 1315.4). Unless the contract sets a date, payment is due 30 days after the later of two dates: the day the agency receives your proper invoice, or the seventh day after the service (the day the agency accepts the service, if it accepts it sooner). In most cases a late payment earns interest at the Prompt Payment rate, 4.75 percent for July 1 through December 31, 2026, and the agency must pay it whether or not you ask (5 CFR 1315.10). See VA transportation contracts.

Receipts families can use for HSAs, FSAs, and taxes

Families who pay with an HSA or FSA, or who deduct medical expenses, need an itemized receipt. Part 9 turns the invoice into one.

• Medical expense deduction. IRS Publication 502 (2025) counts amounts paid for transportation primarily for and essential to medical care, including bus, taxi, train, or plane fares and ambulance service, as medical expenses. Only the part of total medical expenses above 7.5 percent of adjusted gross income is deductible.
• Health FSA. The FSA must get a written statement from an independent third party showing that the medical expense was incurred and its amount, plus the account holder’s statement that no other plan paid it (Publication 969, 2025). A paid receipt from your company, with the dates and amounts, fills the first part.
• HSA. The account holder must keep records showing each distribution paid a qualified medical expense not paid from another source (Publication 969, 2025). Your receipt is that record.
• Mileage. The IRS medical mileage rate, 20.5 cents a mile for January 1 through June 30, 2026 and 23.5 cents for July 1 through December 31, 2026, takes the place of actual gas and oil costs when a family uses a car for medical care. When a family pays you, the expense is the fare they paid you.

Write “Medical transportation” as the service, never the diagnosis, and let the family’s tax preparer decide what they can claim.

Keep invoice records and send the right tax form

1. Keep a copy of every invoice with its trip logs. The IRS says to keep records that support income until the period of limitations for that return runs out: generally 3 years after you file, 7 years if you claim a bad debt deduction, and at least 4 years for employment tax records (updated June 30, 2026). Keep them longer when a facility agreement or broker contract requires it.
2. Match every payment to its invoice. Record the invoice number, the amount, and the date on each payment, and follow up on anything past due every week. See NEMT accounts receivable.
3. Send a Form W-9 with your first invoice to a facility. Payers use it for your legal name and taxpayer ID when they report payments to the IRS. For tax years beginning after 2025, the threshold for most of those reports rose to $2,000 a year (IRS instructions for Forms 1099-MISC and 1099-NEC, 12/2026 revision). The payer decides which form applies and whether a payment to a corporation must be reported, so answer its W-9 request quickly.
4. Review the layout once a year. Update it when your rate sheet, your facility agreements, or your payers’ invoice rules change.