NEMT Standing Order Form: Set Up Recurring Rides for Dialysis and Therapy

A dialysis rider needs the same two rides three days a week, every week. Booking each ride by hand invites a missed date or a wrong time. A standing order sets the schedule once. This form collects everything a standing order needs, whether it goes to a Medicaid broker for approval or is the order itself for recurring rides a facility or family pays you for.

How to use this template

1. Find out who files it. For Medicaid rides, the broker’s own form or portal is the one that counts, and many programs want it from the rider’s care team, as in New York and Delaware. Give this form to the center’s social worker or scheduler as a worksheet, then keep a copy. For rides a facility or family pays for, this form is the order.
2. Fill in one form per rider, per destination. A rider who goes to dialysis and to physical therapy needs two forms, because the days, times, and end dates differ.
3. Write the week row by row. Put the appointment or chair time for each day first. Work back to a pickup time that gets the rider there before it, and write the return rule for that day.
4. Set a start date and an end date. Keep the end date within the payer’s limit, and write the renewal due date on your calendar before the payer’s lead time runs out.
5. Record every approval and form on file. Note the approval number, and the medical necessity form with its signed and expiration dates. In Illinois fee-for-service, one certificate of transportation services (HFS 2271) can cover recurring wheelchair van and service car trips from home for up to 180 days, and a change in medical need or level of transport needs a new one (HFS handbook, March 11, 2024).
6. Keep the same driver when you can. MTM Health’s Virginia handbook (approved August 10, 2026) 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.
7. Log every change in Part 11. Days, times, place, level of service, and pauses for hospital stays all go in the log with the name of whoever approved them.
8. Put each ride on the day’s manifest. A standing order still turns into two legs on each treatment day. Copy them to the driver’s daily manifest, and log each leg on a trip log.

The template

Print it, or copy the fields into your scheduling system. Circle the choices that apply.

Part 1: Request

Field	Entry
Type of request: new / change / renewal / stop
Date of this request
Filed by: name and title
Facility, phone, and work email
Sent to the broker or plan on (date), by portal, fax, or phone
Broker’s reference or approval number

Part 2: Rider

Field	Entry
Rider’s full name and date of birth
Medicaid or health plan ID, if a program pays
Rider’s phone, and a second number
Caregiver or family contact, and phone
Language the rider speaks

Part 3: Where the rider goes

Field	Entry
Facility name
Street address, building, suite, and department
Entrance to use, and where the van waits
Facility phone, and the direct line for rides
Treatment type: dialysis / chemotherapy / radiation / infusion / physical or occupational therapy / behavioral health / adult day / other
Facility opening and closing times

Part 4: Weekly schedule

Write “Will-call” in the return column when the rider or the center calls for the ride home.

Day	Rides this day?	Appointment or chair time	Pickup time	Return: set time or will-call	Notes
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Part 5: Pickup

Field	Entry
Pickup address, apartment, or room number
Door or entrance, parking, and any gate code
Steps between the door and the vehicle, and any ramp or elevator
Who brings the rider out, and who receives the rider at home after the return

Part 6: How the rider travels

Question	Answer
Walks without help / cane / walker / manual wheelchair / power wheelchair or scooter / stretcher
Can the rider move from the wheelchair to a vehicle seat? Yes / No
Weight of the rider with the wheelchair or scooter
Help needed: curb to curb / door to door / door through door / hand to hand
Oxygen brought by the rider, and liters per minute
Stretcher riders: bed or treatment chair ready on arrival? Yes / No
How the rider usually feels after treatment, and help needed on the return

Part 7: Who rides along

Question	Answer
Escort or attendant on these rides: name, and which days
Children riding: ages, and who brings each car seat
Service animal? Yes / No

Part 8: Dates and approvals

Field	Entry
Start date
End date (within the payer’s limit)
Renewal due by
Medical necessity form on file: type, date signed, expiration date
Other forms on file, such as parental consent for a minor
Preferred or designated transportation company, where the program allows one

Part 9: Price and billing (private and facility-paid rides only)

Field	Entry
Price per one-way ride, and what it includes
Billing: weekly invoice / monthly invoice / card on file
Billing contact, and purchase order number if any
Notice needed to cancel a ride, and any fee

Part 10: Closures, emergencies, and backup

Field	Entry
The center’s holiday and closure schedule is sent to us by (name)
Center’s emergency phone, and its alternate number
Backup center if this one cannot open
Who tells us when the rider is in the hospital or away
Bad weather plan: who calls whom, and by what time

Part 11: Change log

Date	What changed	Who asked	Who approved, and the reference number	Effective date

Part 12: Signatures

Signer	Name and title	Signature	Date
Person filing the order
Rider or representative (private and facility-paid rides)
Transportation company

Standing order rules by program

Each program sets what counts as a standing order, who files it, how early, and how long it lasts.

Program	What qualifies	Who files it	When to file	How long it lasts
New York, Medical Answering Services (policy effective October 1, 2020)	Recurring appointments at the same location, usually the same days and times each week, such as dialysis, chemotherapy, or methadone treatment	The medical provider or its staff, through the portal. Riders, family, and transportation companies may not.	At least 3 business days before the start date	No more than six months from the start date, then renewed by the medical provider
Illinois fee-for-service, Transdev (HFS handbook, March 11, 2024)	Trips to the same medical source for the same services more than three times a month	By fax or the PassPORT portal, not by phone. Transportation providers may submit.	At least 7 business days before services begin, with the medical documentation	One certificate of transportation services (HFS 2271) covers recurring wheelchair van and service car trips from home for up to 180 days
Delaware, Modivcare (September 2026)	Trips for treatment at least three days a week for three months or more, such as dialysis, chemotherapy, radiation, substance use treatment, or medical adult day care	A nurse, social worker, caseworker, case manager, or other health professional involved in the care	At least 3 days before the first trip	Set by the start and end dates on the form. Changes go by phone or on a new form.
Virginia fee-for-service, MTM Health (trips from October 1, 2026)	Repeating trips for services such as dialysis, chemotherapy, infusion, therapy, behavioral health, wound care, and adult day care	Facilities book rides by phone or MTM Health’s facility portal	Routine rides at least 5 business days ahead	Up to six months at a time
Wisconsin, and ten Minnesota counties, MTM Health (September 2026)	Recurring trips	By phone or MTM Health’s online portal	Routine rides at least 2 business days ahead in Wisconsin and 3 days in Minnesota	Dialysis up to six months at a time, other standing orders up to three months
Georgia Medicaid (July 1, 2026)	An NEMT trip on a set schedule, such as every Tuesday at 2:00	Arranged with the broker	Routine rides at least 3 business days ahead	The broker must update or confirm each standing order every 30 days. A stretcher standing order needs a letter of medical necessity.

Wisconsin has picked Verida to replace MTM Health as its statewide broker (notice of intent, May 21, 2026). As of September 2026, the state had set no switch date. When it does, ask how existing standing orders move to the new broker.

The published lists of what goes on a standing order request share a core, and the template has a field for each:

Detail	New York (MAS portal)	Delaware (Modivcare form)	Illinois (Transdev may verify with the physician)
Rider’s name and ID	Name and CIN	Name, Medicaid number, date of birth	Name, address, phone, and RIN
Days and times	Appointment days and times	Days checked, appointment and return times	Appointment dates and times already set
Start and end	Effective date and end date	Start and end dates	Number and expected length of the visits
Destination	Address and special directions	Facility, address, building, suite, department	Medical provider’s name and address
Treatment	Treatment type	Treatment type	Purpose of the appointment, and why ongoing visits are needed
How the rider travels	Level of service, with medical justification if not on file	Ambulatory, cane, walker, wheelchair type, stretcher, oxygen, weight, height, stairs	Information to set the level of transportation
Others riding	Medical escort and number of extra riders	Escort	Not listed
Transportation company	Preferred company, if any	Not listed	Company name and provider number
Contact and sign-off	Facility contact’s name, phone, and email, plus an attestation	Name, signature, and title	Not listed

New York adds a security step under the same October 1, 2020 policy. The person entering a standing order confirms their identity with a code sent to a work email address, and personal email accounts are not accepted. New York’s Form-2015, which justifies the mode of transportation, can cover a standing order (policy effective June 6, 2022), and the medical provider must update it when the rider’s status changes. For the paperwork itself, see medical necessity form and prior authorization.

What a dialysis standing order needs

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says in-center patients get a fixed time slot, usually three times a week: Monday, Wednesday, and Friday, or Tuesday, Thursday, and Saturday. Each session lasts about 4 hours, and some centers offer treatment three nights a week. That fixed slot is the chair time in Part 4. Build every pickup time back from it.

Returns need the most care. NIDDK says standard hemodialysis can leave people tired or washed out for several hours. Write in Part 6 what help the rider needs on the way home, and decide in Part 4 whether each return is a set time or a will-call. See will-call trip and managing will-call trips.

Know where your job ends at the center door. Georgia’s manual (July 1, 2026) says the dialysis team takes over the rider’s care on arrival, including weighing the rider and the transfer to the dialysis chair. Wheelchair rides there are door to door, with no lift help to the chair. Stretcher rides are bed to bed or treatment chair, and the center must have the bed or chair ready when the rider arrives.

Two federal rules for dialysis centers belong on the form:

• Emergencies. Every center must keep an emergency plan, arrange with other dialysis facilities or providers to take its patients if it must limit or stop operations, and run a patient orientation program. Its staff must be able to tell patients what to do, where to go, and whom to call, including an alternate emergency phone number for the center (42 CFR 494.62). Ask for both numbers and the backup center, and write them in Part 10.
• Discharges from the center. A center may discharge or transfer a patient only for reasons the rules list, such as the center closing, no longer being paid, or no longer being able to meet the patient’s needs (42 CFR 494.180(f)). Patients have the right to 30 days’ written notice before an involuntary discharge (42 CFR 494.70(b)). When the reason is disruptive and abusive behavior, the center must also try to place the patient at another facility, and a shorter process is allowed only for immediate severe threats to others. Ask the social worker to tell you when a rider is moving, so you can end one standing order and start the next.

The dialysis transportation guide covers how to win and route this work.

Keep standing orders current

Changes need approval first

A standing order is only as good as its last approved version. New York’s policy manual (effective August 25, 2023) says any change to trip details, such as the location or day, must be approved before the service, or payment may be denied. In Illinois fee-for-service, providers contact Transdev to correct errors or make changes (HFS handbook, March 11, 2024). Modivcare in Delaware takes changes by phone or on a new standing order form (September 2026). Never change a Medicaid standing order just because the rider or the center asks you to. Send the change through the broker, then write it in Part 11.

Renew before the end date

Put the renewal date on your calendar the day the order is approved. New York standing orders last no more than six months, and the transportation manager sends reminders before one expires (MAS policy, effective October 1, 2020). Georgia’s broker must update or confirm each standing order every 30 days from its effective date (manual, July 1, 2026). New York denies reimbursement for non-emergency rides without prior authorization, so a ride after the end date may never be paid.

Approval is not payment

New York’s policy manual (August 25, 2023) says prior authorization does not guarantee payment, and unmet provider or rider eligibility rules can still deny a claim. Illinois (HFS handbook, March 11, 2024) makes providers wait for the authorization notice before billing, rejects claims that do not match the approval, and makes the provider check the rider’s eligibility on the day of each trip. Arizona’s fee-for-service manual (revised July 31, 2026) bars date-span or bulk billing of dialysis trips. Each date of service is billed on its own, with actual loaded miles backed by odometer readings.

Plan for holidays and hospital stays

Holidays, storms, and hospital stays break standing schedules. Ask each center for its holiday schedule in writing, note in Part 10 who tells you when a rider is in the hospital, and tell the broker the same day a rider will miss a stretch of treatments. The NEMT standing orders guide covers the weekly routine for keeping a full book of standing orders current. For one-time rides, use the trip request form.