NEMT Service Agreement Template for Private-Pay Riders and Families

A rider who pays you directly, or whose daughter pays, wants to know three things before the first pickup: what each ride costs, what happens when plans change, and who to call. A signed service agreement answers them in writing. It is what lets you charge a deposit or a late cancellation fee without an argument, and it tells your dispatcher who may book, who gets updates, and who pays. Use it for standing rides, such as three dialysis runs a week, and for long trips that need a deposit.

This agreement is for a person or a family who pays. When a hospital, nursing home, or day program pays, use the facility transportation agreement instead.

How to use this template

1. Fill in your terms first. Complete Parts 1, 5, 6, 7, 9, and 14 before you meet the family. Write your prices in Part 5, or attach your rate sheet and write its date. Copy the wait and fee terms in Part 7 from your no-show policy, and attach your passenger conduct policy for Part 10. Cross out any charge you do not use.
2. Sort out who signs. The rider signs if they can decide for themselves. A family member who pays signs as the payer. Someone signing for a rider who cannot decide needs legal authority, such as a guardianship order or a power of attorney, and you keep a copy.
3. Ask about Medicaid before you quote. If the rider has Medicaid or a Medicaid health plan, covered rides go through the plan or its broker, and Part 13 limits this agreement to rides Medicaid does not pay for.
4. Quote each standing ride as one total. Part 5 has a line for the full price of each ride, including every fee you charge on every ride.
5. Get reminder consent on its own line. Part 11 asks separately about reminders and about promotional messages, and the payer and the rider can answer differently.
6. Write down where it was signed. If you sign it in the rider’s home for $25 or more, or anywhere else outside your office for $130 or more, give the 3-day cancellation notice the FTC requires and print the bold statement in Part 15 (see below).
7. Keep card details off this form. If the payer wants a card on file, use the credit card authorization form alongside it.
8. Give a copy the same day. Hand over a paper copy, or email a PDF the signer can save and print.
9. Update it when the deal changes. New prices take effect only after the notice in Part 14. A new rider, a new payer, or a new kind of ride needs a new signature.

The template

Print it, or copy the fields into your booking system. Circle or initial each choice that applies.

Part 1: The transportation company

Field	Entry
Company legal name, and the name riders know you by
Business address
Phone for booking and changes, and its hours
Phone or email for billing questions
After-hours number for a ride already on the way

Part 2: The rider

Field	Entry
Rider’s full name
Rider’s phone
Usual pickup address, with gate codes or entry notes
Mobility: walks / walks with help / wheelchair, rider stays seated / wheelchair, rider transfers / scooter / other
Equipment that rides along: walker, folding wheelchair, oxygen, other

Leave diagnoses, medications, and the reason for each visit off this form. Ride needs that dispatch must know belong on the rider profile form.

Part 3: Who signs and who pays

Field	Entry
The rider signs for themselves: yes / no
If no, the person signing for the rider, and their role: court-appointed guardian / agent under a power of attorney / other legal authority
Copy of the guardianship order or power of attorney received on (date)
Payer’s full name, if not the rider
Payer’s relationship to the rider
Payer’s phone, email, and billing address

Part 4: Rides this agreement covers

Ride	Days and times	Pickup	Drop-off	Mobility from Part 2
Standing ride 1
Standing ride 2
Standing ride 3
One-time or long-distance trip

Each standing ride includes the return trip: yes / no. Return pickup: at a set time / when the rider or the clinic calls.

Part 5: Prices and how they are figured

All amounts are in U.S. dollars. Prices come from the rate sheet dated ________, unless written here.

Charge	Amount	How it is figured
Base fee for each one-way ride	$	Once for each pickup
Rate per mile	$	Miles with the rider aboard, by the shortest practical route
Waiting	$ per ______ minutes	After the first ______ minutes at each stop
Extra stop the rider asks for	$	Each stop added to the booking
Rides before ______ or after ______, weekends, and holidays	$ or ______%	Added to the base fee
Added service the rider asks for, such as a second staff member	$	Only when booked in advance
Full price of each standing ride in Part 4	$	Includes every fee charged on every ride. Government taxes, if any, are listed separately.
Written quote for the one-time or long-distance trip	$	Quote dated ________ is attached

The same trip costs the same for every rider. A wheelchair, a lift, or a service animal does not raise the price.

Part 6: Deposits, billing, and payment

Term	Entry
How you pay: card on file (separate authorization form) / invoice / check / cash
When you are charged or billed: after each ride / weekly on ______ / monthly on ______
Invoices are due within ______ days
Deposit for the one-time or long-distance trip: $______ or ______% of the quote, paid when it is booked
Balance of that trip is due: before pickup / after the ride
Deposit refund: in full if you cancel at least ______ hours before pickup
If a balance is ______ days late, new rides wait until it is paid: yes / no
Receipts go to (name and email), and show only dates, trips, and amounts

Part 7: Cancellations, no-shows, and waiting

Term	Entry
Cancel without charge up to ______ hours before pickup
Late cancellation fee, after that cutoff	$
The driver waits ______ minutes after the scheduled pickup time, and calls or texts ______ times, before leaving
No-show fee, when the rider is not at the pickup after that wait	$
If we are more than ______ minutes late, you may cancel that ride without charge
Bad weather or road closures: either side may cancel that ride without charge

Before leaving, the driver records the arrival time, the wait, and each call or text, and gets an OK from dispatch.

Part 8: Who may ride along

Term	Entry
Companions allowed on each ride (seats permitting)
Charge for each companion: none / $______
Children under ______ ride only in a car seat supplied by: the family / us
Service animals	Always welcome, never charged
Pets that are not service animals: in a carrier / not allowed

The rider is never required to bring an attendant.

Part 9: What the driver will and will not do

Service	Included
Level of help: curb to curb / door to door / through the door to the front desk
Help with the ramp, lift, and wheelchair securement	Always
Carry bags, a walker, or a folded wheelchair, up to ______ items	Yes / no
Help on steps, up to ______ steps	Yes / no
Wait inside the clinic during the visit	Yes / no
Stops not in the booking, such as a pharmacy	Only when booked, at the Part 5 price
Personal care such as toileting, feeding, or dressing	Not provided
Giving medications or medical care	Not provided

Part 10: The rider’s part

1. Be ready at the pickup address when the pickup time starts.
2. Wear a seat belt. A wheelchair rides secured in the vehicle’s securement area. Moving to a vehicle seat is the rider’s choice.
3. Tell us before the next ride about a new wheelchair, oxygen, or a change in how the rider moves.
4. Follow the attached passenger rules for safety and conduct.

Part 11: Reminders and messages

Message	Number to use	Yes or no	Signature of the person whose phone it is
Automated texts: ride reminders and driver updates
Automated or recorded calls: ride reminders and driver updates
Promotional texts and calls, such as new services or specials

By signing yes to promotional messages, you allow us to send ads and offers to that number by automated texts and calls, including recorded calls. You do not have to agree to promotional messages to book or buy rides. To stop any messages, reply STOP or tell us any other way. We stop as soon as we can, and always within 10 business days.

Part 12: Who we may talk to about the rider’s rides

Name	Relationship	Phone	May book or cancel rides	Gets ride updates
			Yes / no	Yes / no
			Yes / no	Yes / no
			Yes / no	Yes / no

Part 13: Medicaid and other coverage

Question	Answer
Does the rider have Medicaid or a Medicaid health plan: yes / no / not sure
If yes, this agreement covers only these rides, which Medicaid does not pay for
Other ride benefit, such as a Medicare Advantage plan or the VA: name it

Rides that Medicaid or a Medicaid health plan covers are booked through the plan or its ride line, and we will never charge you for them, for a late cancellation, or for a no-show on one. Tell us before the next ride if the rider’s coverage changes.

Part 14: Changes and ending the agreement

Term	Entry
This agreement starts on
It runs until (date), or until either side ends it
Price changes take effect ______ days after we tell you in writing
You may end it at any time by telling us by ______. Rides already given stay due, and Part 6 sets any deposit refund.
We may end it with ______ days’ written notice, or at once if a rider’s conduct puts anyone at risk

Part 15: Signatures

I have read this agreement and received a copy. I agree to the prices and terms above for the rides in Part 4.

When the FTC Cooling-Off Rule applies (see Office use), print this statement in bold type of at least 10 points, right above the signatures: You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation form for an explanation of this right.

Signer	Signature	Printed name	Date
Rider
Payer, if not the rider
Guardian or agent, if signing for the rider
For the company

Signed at: our office / the rider’s home / another place: ________ / by phone, mail, or online. Signed on paper / signed electronically.

Office use only

Item	Date and initials
Guardianship order or power of attorney copied and filed
Medicaid status checked, and covered rides sent to the plan
FTC notice of cancellation given (signed at the rider’s home for $25 or more, or elsewhere outside the office for $130 or more)
Message choices in Part 11 entered in the booking system
Card authorization form on file, if paying by card
Copy given to each signer, and how

Rides Medicaid pays for stay out of this agreement

Private pay covers rides that the rider, a family, or a facility pays for because no program does, and the private pay NEMT guide explains who those riders are, how to price their rides, and the state rules for Medicaid members who choose to pay. The one firm line is Medicaid: a ride Medicaid covers is never billed to the member. Medicaid’s payment, plus any cost sharing the state plan sets, is payment in full (42 CFR 447.15), and CMS says states and providers may not charge a member for a no-show (SMD 23-006, September 28, 2023).

The same holds when a health plan pays for rides. A member of a Medicaid health plan, including the prepaid ambulatory health plans some states use for rides, is not liable for covered services when the state or the plan does not pay the provider (42 CFR 438.106). That is why Part 13 asks about coverage before anything else. Broker agreements can go further and bar charging their members at all, so read each one you hold.

What you may charge, and how to state the price

Wheelchair riders pay the same price for the same trip

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 (49 CFR 37.5(d)). DOT’s interpretation in Appendix D to Part 37 counts a higher price for the lift-equipped van, higher mileage for an accessible vehicle, and an extra charge for a service animal as special charges, while fees every rider pays stay allowed. So Part 5 prices the trip, not the rider, and Part 8 never charges for a service animal, which must be allowed to ride along (49 CFR 37.167(d)). ADA requirements for NEMT and the wheelchair section of the rate sheet walk through DOT’s examples.

Parts 8 to 10 follow the other ADA rules on the ride itself. You may not require a rider with a disability to travel with an attendant (49 CFR 37.5(e)), and you do not have to provide personal care such as toileting, feeding, or dressing (Appendix D). Your staff must help with securement systems, ramps, and lifts where needed or on request, you may require that a wheelchair be secured, and you may recommend but not require a move to a vehicle seat (49 CFR 37.165).

Some states require all-in prices

As of October 2026, California bars advertising, displaying, or offering a price for a service that leaves out any mandatory fee, other than government taxes or fees on the transaction (Civil Code 1770(a)(29)). The Attorney General’s questions and answers say the rule has applied since July 1, 2024, covers most services bought for personal use, and makes these points:

• No add-on percentage. Listing one price and saying a percentage fee will be added does not comply, and neither does disclosing extra fees before the customer finalizes.
• Optional and later fees. Fees for optional services need not be in the advertised price. Fees that depend on the customer’s later conduct, such as a late return fee for rented equipment, are not mandatory.
• Card fees. A card processing fee is not mandatory if the customer can avoid it by paying another way. If you accept only cards, it is mandatory and belongs in the price.
• Unknown prices. A business that does not yet know what it will charge should wait to show a price until it does.

Minnesota’s similar rule has applied since January 1, 2025 (Statutes 325D.44, subdivision 1a). It counts a fee as mandatory when it must be paid to buy the service, is not reasonably avoidable, or a reasonable person would expect it to be included. A service whose total depends on distance or time complies if you clearly disclose what sets the total, every mandatory fee, and that the total may vary (subdivision 1a(g)). In Minnesota, put those three things next to any per-mile price. The federal FTC fee rule covers only live-event tickets and short-term lodging (16 CFR 464.1), so state law decides this for rides. The full price line in Part 5 answers it in every state. Card surcharges follow card network rules and state law, which the credit card authorization form covers.

Who can sign for an adult rider

A rider who can make their own decisions signs their own part, even when a son or daughter pays. When the rider cannot, the person signing needs legal authority, and the document that gives it also sets its limits:

• A guardian acts under a court order. Read what the order covers.
• An agent under a financial power of attorney can usually pay the rider’s bills. Under the Uniform Power of Attorney Act (2006), section 213, authority over personal and family maintenance lets the agent pay for necessary health care and other current living costs. The act’s comment says that authority does not let the agent make health care decisions. North Carolina’s version is General Statutes 32C-2-213, and your state’s law may differ.
• An agent under a health care power of attorney makes health care decisions within the powers it grants.

Keep a copy with the agreement, and note it in Office use. If your company is a HIPAA covered entity, a person with legal authority to make the rider’s health care decisions, such as a health care agent or a court-appointed guardian, is the rider’s personal representative and is treated as the rider for the information that authority covers (45 CFR 164.502(g)(2); HHS guidance last reviewed January 5, 2024). For family members and friends without that authority, you may share what is directly relevant to their part in the rider’s care or payment, if the rider agrees or does not object when given the chance (45 CFR 164.510(b)). Part 12 records those choices. HIPAA for NEMT providers explains whether your company is covered.

Signing electronically, or in the rider’s home

Electronic signatures

Federal law bars denying a contract or signature legal effect only because it is electronic (15 U.S.C. 7001(a)). Where a law requires a contract to be in writing, an electronic copy can be refused if it cannot be kept and accurately reproduced by everyone entitled to keep it (7001(e)). Send each signer a PDF.

A separate rule applies to notices that a law requires you to give a consumer in writing, such as the cancellation notice below. You may send those electronically only after the consumer agrees. Before agreeing, the consumer must be told about the right to paper copies, how to withdraw consent, and the hardware and software needed, and must consent in a way that shows they can open the electronic form you will use (7001(c)).

The FTC Cooling-Off Rule

The FTC treats a sale of consumer services as a door-to-door sale when you personally solicit it and the buyer agrees somewhere other than your place of business: $25 or more at the buyer’s home, or $130 or more at another place. That holds even when the buyer invited you (16 CFR 429.0). A deal made entirely by mail or phone, with no other contact before the service, is excluded.

When the rule applies, under 16 CFR 429.1 you must:

1. Give the buyer a completed copy of the agreement, in the language used in the sales talk, with a bold statement next to the signature that the buyer may cancel before midnight of the third business day.
2. Give the buyer two completed copies of the FTC’s Notice of Cancellation form, with your name, your address, the date, and the cancel-by date filled in.
3. Tell the buyer out loud about the right to cancel.
4. Refund all payments within 10 business days after a valid cancellation.

The Signed at line in Part 15 and the Office use row show whether you owed the notice. Some states add their own home-sales rules, which the FTC rule does not fully override (16 CFR 429.2).

Consent for text and call reminders

Part 11 collects two consents, because federal rules treat ride reminders and sales messages differently:

• Reminders and driver updates. An autodialed or prerecorded call to a cell phone needs the called party’s prior express consent, unless it is made for an emergency (47 CFR 64.1200(a)(1)). The same rules cover automated texts (64.1200(a)(10)). A yes in Part 11, signed by the person whose phone it is, records that consent.
• Promotional messages. An automated message that advertises needs prior express written consent: a signed agreement naming the phone number, with a clear statement that signing allows automated sales calls or texts and that the signer does not have to agree in order to buy (64.1200(a)(2) and (f)(9)). The sentence under the Part 11 table makes both points, and a yes to reminders never counts as a yes to sales.
• Stopping messages. As of October 2, 2026, a person may revoke either consent by any reasonable method. A reply of stop, quit, end, revoke, opt out, cancel, or unsubscribe always counts, and you must honor each request within 10 business days (64.1200(a)(10)). An FCC order adopted September 30, 2026 (FCC 26-67) will let you name the only opt-out methods you accept, starting 30 days after it is published in the Federal Register. Until then, Part 11’s promise to accept a stop request made any other way is the one the rule requires.

Each violation can cost $500 in a private lawsuit, and a court may triple that for a willful or knowing violation (47 U.S.C. 227(b)(3)). Keep each signed Part 11, and log every stop request with its date. HIPAA texting for NEMT covers what a reminder may say and the narrow health care exemption.

Rules that sit outside this agreement

A signed agreement does not replace a permit, a policy, or a card rule. Medicaid enrollment and broker credentials do not by themselves let you carry the public for pay, so check your state and city for-hire rules in NEMT license requirements before you sign private riders. A paid trip across a state line can bring in federal operating authority and insurance minimums, which long-distance medical transport covers. Card-on-file charges, deposits by card, and surcharges belong on the credit card authorization form. Who may ride with a member on broker trips is in can a caregiver ride with NEMT.