# NEMT Trip Log Template: A Free Printable Log for Every Ride

Canonical URL: https://nemtguide.com/templates/nemt-trip-log-template/ · Updated 2026-09-28

A NEMT trip log is the record of one ride leg that backs up your claim. It needs the rider and Medicaid ID, trip number, level of service, pickup and drop-off addresses, times, and odometer readings, the vehicle plate, and the driver's and rider's signatures. Print the free template below, fill one record per leg, and keep it as long as your state and broker require.

- Fill one record for each one-way leg, because each leg is billed and audited on its own.
- Odometer readings at pickup and drop-off are the proof behind every loaded mile you bill.
- The driver never signs for the rider. Arizona bans it even when the driver is a relative.
- Arizona fee-for-service trips must use the state's own Daily Trip Report instead of this form.
- Keep logs at least five years after billing in Minnesota and six years after payment in New York.

Every Medicaid program pays you only for rides you can prove. Federal rule 42 CFR 431.107 makes every enrolled provider agree to keep the records that show what services it gave, and to hand them over to the state Medicaid agency, the HHS Secretary, or the state's Medicaid fraud unit on request. The trip log is that record. This one covers the fields state and broker rules most often ask for, with the rule behind each field below it.

## How to use this template

1. **Check your state first.** Arizona's fee-for-service program accepts only its own AHCCCS Daily Trip Report (Exhibit 14-1 of its transportation manual, revised July 31, 2026), and bars providers from making their own version. If you drive there, use the state form. Everywhere else, this template works as your paper log or as the checklist for an electronic one.
2. **Print one Part 1 per driver, per vehicle, per day.** If a driver switches vans mid-shift, start a new Part 1 for the second van. Arizona requires a new trip report for each separate vehicle for the same reason. The start-of-shift odometer can come from the morning [vehicle inspection](https://nemtguide.com/templates/nemt-vehicle-inspection-checklist/).
3. **Print one Part 2 for every leg.** A [trip leg](https://nemtguide.com/glossary/trip-leg/) is one ride from A to B. A round trip to dialysis is two legs, and each is its own record.
4. **Write it as it happens.** Record times and odometer readings at the curb, not at the end of the shift. New York pays only when records are contemporaneous, meaning made at the time of the ride.
5. **Fix mistakes the approved way.** Use pen. Draw one line through a wrong entry and write the right one next to it. Arizona does not accept erasures or white-out.
6. **Collect the sheets daily.** Match each record to the day's [manifest](https://nemtguide.com/templates/nemt-daily-manifest/) before you bill. Any leg with a blank field gets fixed that day or held back from billing.
7. **Store them like health records.** A trip log holds a rider's name, Medicaid ID, and where they get care. Keep it locked up or in a system only your staff can open.

## The template

### Part 1: Driver and vehicle (one per vehicle, per day)

| Field | Write the entry here in pen |
|---|---|
| Company name and phone | |
| Medicaid provider ID or NPI | |
| Date of service (mm/dd/yyyy) | |
| Driver's printed full name | |
| Driver's license number and state | |
| Driver ID from Medicaid or broker, if any | |
| Vehicle plate number and state | |
| Vehicle make, color, fleet number | |
| Vehicle type (sedan, van, wheelchair, stretcher) | |
| Odometer at start of shift | |
| Odometer at end of shift | |
| Page ___ of ___ | |

### Part 2: Leg record (one per leg)

| Field | Write the entry here in pen |
|---|---|
| Trip or authorization number | |
| Leg: A (to appointment), B (return), other | |
| Rider's full name | |
| Rider's Medicaid ID | |
| Level of service authorized | |
| Level of service provided | |
| Escort or attendant, and relationship | |
| Other riders on board (how many) | |
| Pickup address, GPS point, or landmark | |
| Scheduled pickup time | |
| Arrived at pickup (time, a.m. or p.m.) | |
| Rider picked up (time, a.m. or p.m.) | |
| Odometer at pickup | |
| Drop-off address | |
| Appointment time | |
| Rider dropped off (time, a.m. or p.m.) | |
| Odometer at drop-off | |
| Trip miles (drop-off minus pickup odometer) | |
| Direct-route miles and how measured | |
| Wait time start and end (only if paid) | |
| Tolls or parking paid (keep receipt) | |
| Amount billed for this leg | |
| Result: completed, no-show, canceled, other | |
| No-show: arrived, left, calls or texts | |
| Notes: delays, changes, incidents | |

### Part 3: Signatures (one set per leg)

| Field | Write the entry here in pen |
|---|---|
| Rider signature, or fingerprint | |
| Person signing for the rider, and relationship | |
| No one could sign: reason, and facility staff signature | |
| Driver signature (not initials, not typed) | |
| Date signed | |

By signing, the driver states: "This record is accurate for the service I provided and the miles I actually drove. I understand that false entries that cause improper payment can lead to civil or criminal action."

## Which rule each field meets

Federal rules do not list trip log fields. CMS says only that trip records should be accurate and complete, and states write the details. The table shows where each field comes from, using states and brokers with clear written rules.

| Field | Why it is on the log | Where it is required |
|---|---|---|
| Rider name and Medicaid ID | Ties the leg to an eligible member | New York manual; Arizona (name, AHCCCS ID, date of birth, mailing address); Minnesota (name) |
| Trip or authorization number | Proves the leg was approved before you drove | MTM Health Virginia (no transport without the trip ID); CareOregon |
| Date of service | Matches the claim line | New York; Arizona; Minnesota; CareOregon |
| Driver's printed name and signature | Shows who gave the ride | New York (full printed name and signature); Arizona (no initials or stamps); Minnesota |
| Driver's license number | Shows the driver was licensed that day | New York |
| Vehicle plate, make, and color | Shows which vehicle carried the rider | New York and Minnesota (plate); Arizona (state, plate or fleet number, make, color) |
| Vehicle type and level of service | Supports the rate you bill | Minnesota (mode of transportation); Arizona (vehicle type); CareOregon (mode) |
| Pickup and drop-off addresses | Supports the mileage | New York; Arizona; Minnesota; CareOregon |
| Scheduled and actual pickup times | Shows on-time service | MTM Health Virginia; CareOregon |
| Drop-off time | Shows when the ride ended | New York; Arizona; Minnesota; CareOregon |
| Appointment time | Shows the rider arrived before the appointment | CareOregon; MTM Health Virginia (drop-off no later than the appointment time) |
| Amount billed for this leg | Ties the record to the claim | CareOregon (trip cost) |
| Odometer at pickup and drop-off | Proves loaded miles | Minnesota; Arizona (trip miles are drop-off minus pickup) |
| Direct-route miles and method | Caps mileage at the shortest reasonable route | Minnesota (the direct-route miles and how they were found); CareOregon (bill only the most cost-effective, reasonably direct route) |
| Escort or attendant name | Supports any attendant charge | Minnesota (extra attendant); Arizona (escort name and relationship) |
| No-show details | Shows the ride was attempted | New York (indicate a no-show); MTM Health Virginia (follow its no-show steps and try the rider by phone or text) |
| Rider signature | Rider confirms the ride happened | Minnesota; Arizona; MTM Health Virginia (in its electronic trip log) |
| Driver statement | Driver confirms the record is true | New York; Minnesota (wording on the template follows its statute) |

Each broker sets its own list, so compare this table with your broker's provider manual and add anything it asks for. The fields also back up your [mileage billing](https://nemtguide.com/guides/nemt-mileage-billing/) and any [wait time](https://nemtguide.com/guides/nemt-wait-time-billing/) you claim.

## State and broker rules that change the log

**Minnesota.** Minnesota Statutes 256B.0625, subdivision 17b, lists 14 elements every trip record must include, from the rider's name to the method used to find the most direct route. Records must be in English and legible. The driver signs a statement that the record is accurate and that misreporting can lead to civil or criminal action. The rider, an authorized party, or the medical provider signs to confirm the ride.

The state may recover payment for any trip documented another way, and it applies these rules to audit findings from January 1, 2020 on. Starting January 1, 2027, or on federal approval if that comes later, Minnesota NEMT providers must also follow the state's electronic visit verification law (section 256B.073). A record from that system can then serve as the trip record if it holds every required element.

**New York.** The Medicaid Transportation Policy Manual (effective August 25, 2023) requires, for every leg, the rider's name and Medicaid ID, date, origin and pickup time, destination and drop-off time, plate number, driver's license number, and the driver's printed name, signature, and statement that the trip was completed. Since April 3, 2023, New York has also required GPS data for every trip, sent to the broker. A dispatch sheet or manifest alone is not accepted as proof of a trip.

**Arizona.** Fee-for-service providers must submit the AHCCCS Daily Trip Report with every claim, in blue or black ink or on a tablet with a real signature. Claims without it are denied. The driver prints their name on page one and signs and dates page two.

**MTM Health in Virginia.** Its handbook (May 2026, approved August 10, 2026) makes a clean claim depend on an electronic trip log with the trip ID, scheduled pickup time, actual pickup time, departure time, arrival time, and the member's signature. Providers have 6 months from the date of service to submit it. A pickup counts as on time from 15 minutes before to 15 minutes after the scheduled time.

**CareOregon in Oregon.** CareOregon's manual (version 1.3, February 2024) lists 15 minimum fields, including scheduled and actual pickup times, appointment time, trip cost, and mileage.

## Trip log mistakes auditors find

HHS OIG reviewed 100 sampled NEMT payments to New York City providers for 2018 and 2019 (report A-02-21-01001, September 12, 2022). For 11 of them, the provider could not show records of the date, the pickup and drop-off locations, the driver, and the vehicle. For 2 more, the provider had no record of the ride at all. On May 28, 2026, OIG announced a new series of audits of state NEMT payments. The announcement notes that NEMT providers must keep records supporting the services they provide.

These are the errors a complete log prevents:

- **A leg with no record.** Every paid leg needs its own sheet or electronic entry.
- **A driver signing for the rider.** Arizona forbids it in every case.
- **A typed name as a signature.** Arizona does not accept it, even on a tablet.
- **Times that do not fit the miles.** MTM Health in Virginia scores providers on trips whose documented minutes and miles do not fit together.
- **Overlaps.** MTM Health in Virginia also flags one driver in two vehicles, or two drivers in one vehicle, at the same time.
- **The wrong level of service.** OIG found a New York payment for a level of service that was not authorized.
- **Miles longer than the direct route.** Minnesota requires the most direct route, and CareOregon lets you bill only the most cost-effective, reasonably direct route.

A [no-show](https://nemtguide.com/glossary/no-show/) needs a record too. New York has drivers wait at least 15 minutes past the scheduled pickup time before marking a no-show, and has providers document every one.

## How long to keep trip logs

| Rule | How long |
|---|---|
| Minnesota Rules 9505.2190 | At least 5 years after the first billing date |
| New York Medicaid Transportation Policy Manual | 6 years after the date of payment |
| CareOregon Transportation Provider Manual | At least 6 years after the ride |
| MTM Health agreement (Pennsylvania version, January 1, 2023) | 10 years, or longer if law or the client requires |

The longest rule that applies to you wins. MTM's agreement also lets MTM and government officials inspect trip and log sheets without notice. For the rest of what to keep, see NEMT record retention and [NEMT trip documentation](https://nemtguide.com/guides/nemt-trip-documentation/).

## Frequently asked questions

### What must a NEMT trip log include?

The core is the same almost everywhere: rider name and Medicaid ID, date, pickup and drop-off addresses and times, the vehicle plate, and the driver's name and signature. Minnesota adds odometer readings at pickup and drop-off, the rider's signature, and the direct-route mileage. New York adds the driver's license number and the driver's statement that the trip was completed. Your broker may add a trip number and scheduled times.

### Can I keep trip logs on a phone or tablet instead of paper?

Usually, yes. Minnesota allows paper or electronic records as long as you can produce them on request. New York accepts a unique electronic driver signature when the system records pickup and drop-off coordinates with a date and time stamp that cannot be changed. Arizona accepts a tablet if the rider and driver sign with a pen or a fingertip. A typed name never counts as a signature there.

### Who signs the trip log when the rider cannot?

In Arizona, a parent, guardian, caretaker, escort, or family member signs and writes their relationship, such as "by J Smith, daughter." If the rider travels alone, the medical provider at the appointment may sign. Minnesota also accepts the medical provider's signature. If no one can sign, the Minnesota driver writes that signatures were requested and not given. The driver never signs for the rider.

### How long do I have to keep NEMT trip logs?

Follow the longest rule that applies to you. Minnesota requires five years after the first billing date. New York requires six years after payment. CareOregon asks its transportation providers for six years after the ride. MTM Health's standard agreement, in the January 1, 2023 version Pennsylvania posts, asks for 10 years. Check your state manual and every broker contract you sign.

### Do I need a separate log for the return trip?

Yes, treat the return as its own leg with its own times, odometer readings, and signature. Each one-way leg is a separate service on the claim, and auditors match each paid leg to its record. A will-call return can happen hours later, sometimes in a different vehicle or with a different driver, so the record must show who drove it and in which van.

### What happens if a trip log is missing or incomplete?

The payment can be taken back. New York recoups any paid claim whose required record is incomplete, unacceptable, or false. Arizona says trip records with missing information are subject to audit error and recoupment. Minnesota may recover payments for trips not documented the way its statute requires. Fix gaps the same day, while the driver still remembers the ride.

## Official resources

- [Minnesota Statutes 256B.0625 (subdivision 17b lists every required trip record element)](https://www.revisor.mn.gov/statutes/cite/256B.0625)
- [New York State Medicaid Transportation Policy Manual](https://www.emedny.org/ProviderManuals/Transportation/PDFS/Transportation_Manual_Policy_Section.pdf)
- [AHCCCS: Daily Trip Report, Exhibit 14-1 (the only version Arizona fee-for-service accepts)](https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/AHCCCSDailyTripReportFinal.pdf)
- [AHCCCS: Daily Trip Report instructions, Exhibit 14-2](https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/FFSChap_14TransportationExhibit2.pdf)
- [CMS: Medicaid Transportation Coverage Guide (SMD 23-006)](https://www.medicaid.gov/federal-policy-guidance/downloads/smd23006.pdf)