# NEMT Trip Request Form: A Free Booking Form for Facilities and Private Riders

Canonical URL: https://nemtguide.com/templates/nemt-trip-request-form/ · Updated 2026-09-29

A NEMT trip request form is the booking sheet a facility, family, or private rider fills in before a ride. It records who rides, the appointment and return times, both addresses and entrances, how the rider moves, who comes along, and who pays. Use the free form below for rides booked with you directly. Medicaid rides are booked through the rider's broker, health plan, or state program.

- Ask how the rider moves, what the rider and wheelchair weigh together, and how many steps are at each door. Those answers decide the vehicle.
- Write down everyone riding along, and who brings each child's car seat. Under Texas Medicaid health plan rules, a missing car seat turns the trip into a member no-show.
- Find out whether the return has a set time or is a will-call, and get a phone number at the clinic.
- A Medicaid member's ride to a covered service belongs to the broker or health plan. Never book it as private pay.
- Ask only what the ride needs. Diagnoses and medical records stay off the form.

Most failed pickups are decided at booking. The van arrives and the rider uses a power chair the sedan cannot carry, lives up a flight of steps, or has a child with no car seat. A trip request form asks those questions once, before anyone picks a vehicle. This one is built for rides booked with you directly by hospitals, nursing homes, dialysis centers, day programs, families, and private-pay riders.

## How to use this template

1. **Use it for rides booked with you directly.** Facilities that pay you, families, and private riders can fill it in, or your dispatcher fills it in on the phone. For a ride that repeats every week, use the [standing order form](https://nemtguide.com/templates/nemt-standing-order-form/) instead.
2. **Ask who pays before anything else.** If the rider has Medicaid and the ride is to a covered service, the ride belongs to the rider's broker or health plan. Send the caller there, and run the ride only after it is assigned to you with a trip number. Medicaid providers must accept the program's payment, plus any copay the program sets, as payment in full ([42 CFR 447.15](https://www.ecfr.gov/current/title-42/section-447.15)), so never quote a Medicaid member a private price for a covered ride. [Private pay NEMT](https://nemtguide.com/guides/private-pay-nemt/) covers when a rider may pay.
3. **Read the questions in order on phone bookings.** Part 6 decides the vehicle, so never skip it. For the phone call around these questions, see NEMT trip intake.
4. **Quote before you book.** Give private riders the full price from your [rate sheet](https://nemtguide.com/templates/nemt-rate-sheet/), including any wait time, and read your cancellation rule aloud. Take card numbers on a separate credit card authorization form, never on this form.
5. **Confirm the day before.** Call or text the rider or facility with the pickup time. Texas Medicaid health plans require most van and car rides, other than discharges and a few other trip types, to be confirmed with the member 24 hours before pickup, and bar contacting members after 9 p.m. local time (UMCM 16.4). The same habit works for private rides.
6. **Turn the request into legs.** A round trip is two legs. Put each one on the driver's [daily manifest](https://nemtguide.com/templates/nemt-daily-manifest/), and copy the level of help and the notes exactly.
7. **File it with the trip record.** Keep the form with the [trip log](https://nemtguide.com/templates/nemt-trip-log-template/) for each leg, where only staff who book and dispatch can see it.

## The template

Fill in one form per rider, per appointment. Circle the choices that apply. Keep confirmations by text or email to the date, time, and pickup place.

### Part 1: Who is booking

| Field | Entry |
|---|---|
| Date and time of this request | |
| Name of the person booking | |
| Facility or agency, if any, and the unit or department | |
| Relationship to the rider: self, family, caregiver, or facility staff | |
| Callback phone and the best time to reach you | |
| Email for the confirmation | |
| Other people the rider says we may update about this ride | |

### Part 2: Rider

| Field | Entry |
|---|---|
| Rider's full name | |
| Date of birth (to tell apart riders with the same name) | |
| Rider's phone, and a second number | |
| Language the rider speaks, and whether an interpreter or relay call is needed | |
| Hearing, vision, or memory needs the driver should know about | |
| Can the rider be left alone at the destination? Yes / No | |

### Part 3: Appointment and return

| Field | Entry |
|---|---|
| Date of the ride | |
| Appointment time, or the time the rider must arrive | |
| When the appointment should end | |
| Return ride: set time ______ / will-call (rider or clinic calls) / one-way only | |
| Clinic phone for the will-call | |
| Does the clinic require an adult to take the rider home? Yes / No | |
| Earliest time the rider can be ready for pickup | |

### Part 4: Pickup

| Field | Entry |
|---|---|
| Place: home, facility, or hospital unit | |
| Street address, apartment, or room number | |
| Door or entrance to use, and where the van can park | |
| Steps between the door and the vehicle (how many), and any ramp or elevator | |
| Gate code, buzzer, or front desk check-in | |
| Who brings the rider out to the driver | |

### Part 5: Drop-off

| Field | Entry |
|---|---|
| Facility or place name | |
| Street address, building, suite, and department | |
| Entrance to use, and the hours the entrance is open | |
| Phone at the destination | |
| Who meets the rider, if the rider cannot be left alone | |
| Stretcher riders: does this place accept stretcher drop-offs? Yes / No | |

### 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 together with the wheelchair or scooter | |
| Seat width of the wheelchair, if wider than standard | |
| Help needed: curb to curb / door to door / door through door / hand to hand | |
| Oxygen: brought by the rider? Portable tank or concentrator, and liters per minute | |
| Other items coming along: walker, folding chair, bags, medical supplies | |
| Anything the driver must know to help safely | |

The help levels are explained in [level of service](https://nemtguide.com/glossary/level-of-service/) and door-through-door service.

### Part 7: Who rides along

| Question | Answer |
|---|---|
| Escort, caregiver, or attendant: names and how many | |
| Children riding: ages, and who brings and installs each car seat or booster | |
| Service animal riding? Yes / No | |
| Total seats needed, and wheelchair spaces needed | |

### Part 8: Payment

| Field | Entry |
|---|---|
| Who pays: rider or family / facility account / Medicaid broker or health plan / other | |
| Medicaid or health plan rides: the broker or plan, and its trip number | |
| Price quoted, and what it covers (base rate, miles, wait time) | |
| Deposit, if any, and how the balance is paid | |
| Facility billing contact or purchase order number | |
| Cancellation rule read to the caller: hours of notice and any fee | |

### Part 9: Hospital discharge (fill in only for a discharge)

| Field | Entry |
|---|---|
| Hospital, unit, and room | |
| Time the patient will be ready | |
| Case manager or nurse, with a direct phone | |
| Do we need to bring a wheelchair? Yes / No | |
| Equipment going home with the patient | |
| Paperwork the hospital sends with the ride | |
| Who will be at home to receive the patient, with a phone | |

### Part 10: Office use

| Field | Entry |
|---|---|
| Request taken by | |
| Vehicle type and driver assigned | |
| Pickup time given to the caller | |
| Confirmation made: date, time, and person reached | |
| Trip number for leg A and leg B | |

## Questions that prevent failed pickups

Each question on the form stops a ride from failing at the door. The rules below come from federal ADA transportation rules, which apply to public and private entities, and from state Medicaid manuals and broker handbooks.

| Ask | What goes wrong if you skip it | The rule behind it |
|---|---|---|
| Weight of the rider with the wheelchair | The lift or ramp is not rated for the load | Lifts on ADA vehicles must have a design load of at least 600 pounds, and ramps 30 inches or longer must hold 600 pounds ([49 CFR 38.23](https://www.ecfr.gov/current/title-49/section-38.23)). You must carry a larger rider and chair when the lift and van can handle them, and may decline when the combined weight exceeds the lift's specifications ([49 CFR 37.165(b)](https://www.ecfr.gov/current/title-49/section-37.165)). |
| Power chair, scooter, or transfer | A sedan arrives for a rider who cannot leave the chair | You may suggest a transfer to a vehicle seat but may not require it. You may require the wheelchair to be secured, and may not refuse a rider because the chair cannot be secured well (49 CFR 37.165). |
| Steps at the door | One driver cannot safely bring the rider down | Modivcare's Delaware request forms ask about stairs on wheelchair and stretcher requests (September 2026). |
| Children and car seats | The trip is lost at the curb | Under Texas Medicaid health plan rules, a trip with no child safety seat, or a parent who cannot install it, is canceled and recorded as a member no-show (UMCM 16.4). MTM Health's Virginia handbook (August 10, 2026) has parents supply seats for children through age seven. |
| Minors riding alone | The driver cannot take the child | Texas Medicaid health plans require a parent, guardian, or authorized adult for members 14 and under, and for members 15 to 17 unless signed consent is shown ahead of time (UMCM 16.4). |
| Oxygen | The rider has no supply for the ride | Georgia Medicaid riders supply and administer their own oxygen, and a rider on a ventilator must bring a trained escort and a battery-powered ventilator (July 1, 2026). Under ADA rules you may not stop a rider from bringing a respirator or portable oxygen, within the federal hazardous materials rules ([49 CFR 37.167(h)](https://www.ecfr.gov/current/title-49/section-37.167)). |
| Service animal | No room is saved | You must let a service animal ride (49 CFR 37.167(d)). Texas Medicaid health plans pay for an approved service animal's space at the adult attendant rate (UMCM 16.4). |
| Anyone else riding | The van is full | MTM Health's Virginia handbook (August 10, 2026) has members say at scheduling if they plan to bring another passenger. |
| Return time or will-call | Nobody knows when to come back | MTM Health's will-call standard is 45 minutes from the call in Virginia and one hour in Wisconsin (September 2026). |

More detail on each is in children in NEMT, transporting riders with oxygen, [service animals in NEMT](https://nemtguide.com/guides/service-animals-in-nemt/), and bariatric transportation. Returns are covered in [will-call trip](https://nemtguide.com/glossary/will-call-trip/).

## What brokers ask on a Medicaid trip request

When a facility books a Medicaid ride, it books with the broker, the health plan, or the state's approval agent, and that request is the one that counts. Three published lists show what they ask:

| Detail | Georgia Medicaid (July 1, 2026) | Illinois fee-for-service, Transdev (March 11, 2024) | Modivcare, Delaware trip request form |
|---|---|---|---|
| Medicaid ID | Yes | Yes (RIN) | Yes, with date of birth |
| Name, address, and phone | Yes | Name, pickup address, and phone | Yes, with room or apartment number |
| Appointment date and time | Yes, and when it will end | Yes | Yes, with return time or will-call |
| Doctor or facility | Name, address, and phone | Doctor's name, destination name, address, and phone | Name, address, building, suite, department |
| Type of service | Type of Medicaid service | General reason for the visit | Treatment type |
| How the rider moves | Type of transportation | Walker, wheelchair, or cane | Ambulatory, cane, walker, wheelchair type, stretcher, weight, height, stairs |
| Special needs | Wheelchair type, walker, oxygen, escort, car seat, service animal | Whether the rider can travel alone | Escort, oxygen in liters, isolation |
| Why not transit | Not listed | Medical or other reason the rider cannot use public transportation | Ambulatory riders living within half a mile of a fixed route stop must use transit unless a restriction form is on file |
| Caller's authority | Not listed | The rider's permission to speak with the caller | Name and signature of the person requesting |

Book early enough for the payer's rule. Discharges and urgent rides have their own clocks.

| Program | Routine rides | Discharges and urgent rides |
|---|---|---|
| Georgia Medicaid (July 1, 2026) | At least 3 business days, counting the day of the call but not the day of the appointment | Honored within 3 hours of the request. Hospitals give the member's name and Medicaid ID, the discharge location and destination, the time, and special needs. |
| MTM Health, Virginia fee-for-service (trips from October 1, 2026) | At least 5 business days | The vehicle arrives within 3 hours of notice that the member is ready. Some discharges need the provider to bring a wheelchair. |
| MTM Health, Wisconsin (September 2026) | At least 2 business days, counting the day of the call but not the day of the appointment | Discharges and urgent trips can be requested with less notice |
| MTM Health, Minnesota, in its ten counties (September 2026) | At least 3 days. Routine rides are booked weekdays, 7 a.m. to 6 p.m. | Discharges and urgent trips are exempt. Urgent rides are booked 24 hours a day. |
| Modivcare, Delaware (September 2026) | 3 business days, until 4 p.m. | Accepted 24 hours a day with a goal of 3 hours. A patient cannot call in their own discharge. |
| Illinois fee-for-service (HFS handbook, March 11, 2024) | Request prior approval at least 7 business days ahead | A physician certification statement (HFS 2270) used for a discharge is valid only for that date |

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, and riders and facilities keep booking with MTM Health until it does.

For discharge work in depth, see [hospital discharge transportation](https://nemtguide.com/guides/hospital-discharge-transportation/). For the necessity paperwork brokers ask for, see [medical necessity form](https://nemtguide.com/glossary/medical-necessity-form/).

## Rules the form follows

### Rider rights under the ADA

The federal ADA transportation rules in [49 CFR Part 37](https://www.ecfr.gov/current/title-49/subtitle-A/part-37) shape several questions on the form:

- **Attendants.** You may not require a rider with a disability to bring an attendant ([49 CFR 37.5(e)](https://www.ecfr.gov/current/title-49/section-37.5)). The form asks who is coming so you can save a seat, not to set a condition.
- **Extra charges.** You may not impose 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)). Ask a transportation attorney before your private price list charges more for a wheelchair. See [ADA requirements for NEMT](https://nemtguide.com/guides/ada-requirements-for-nemt/).
- **Service animals and oxygen.** Service animals must be allowed to ride, and a rider may travel with a respirator or portable oxygen within the federal hazardous materials rules (49 CFR 37.167(d) and (h)).
- **Ways to book.** You must give riders with disabilities enough information and communication options to learn about the service and schedule it (49 CFR 37.167(f)). Take bookings by phone as well as online, and read the form aloud to riders who cannot fill it in.

### Health privacy

Whether HIPAA reaches your company depends on your payers and how you bill. [HIPAA for NEMT providers](https://nemtguide.com/guides/hipaa-for-nemt/) explains the tests. If you are a covered entity or a business associate, these rules apply to the form:

- **Minimum necessary.** Covered entities and business associates must make reasonable efforts to limit health information to the minimum needed when they use, disclose, or request it ([45 CFR 164.502(b)](https://www.ecfr.gov/current/title-45/section-164.502)).
- **A standard form for routine requests.** When a covered entity routinely requests health information from another covered entity, such as a hospital, it must use policies or standard protocols that limit the request to what is reasonably necessary. It may not ask for a whole medical record unless that is specifically justified ([45 CFR 164.514(d)](https://www.ecfr.gov/current/title-45/section-164.514)). A fixed booking form that asks how the rider moves, and never why, meets that purpose.
- **Family and caregivers.** A covered entity may share information directly relevant to a family member's or friend's involvement in the rider's care, when the rider agrees or does not object ([45 CFR 164.510(b)](https://www.ecfr.gov/current/title-45/section-164.510)). Part 1 records the people the rider names.

### Who pays for what

Original Medicare covers ground ambulance rides when traveling in any other vehicle could endanger the rider's health. A wheelchair van ride for a rider whose only coverage is Original Medicare is usually paid by the rider, the family, or a facility. For facility-paid rides, put the booking rules and rates in a signed [facility transportation agreement](https://nemtguide.com/templates/facility-transportation-agreement/) and use this form for each ride under it. For private riders, set your no-show and cancellation terms with the [no-show policy template](https://nemtguide.com/templates/nemt-no-show-policy/). Never charge a Medicaid member for a no-show. CMS says states and providers may not ([SMD 23-006](https://www.medicaid.gov/federal-policy-guidance/downloads/smd23006.pdf), September 28, 2023).

## Frequently asked questions

### What should a NEMT trip request form include?

The person booking and a callback number, the rider's name and phone, the date and appointment time, the return plan, both addresses with the entrance and any steps, how the rider moves and the weight with any wheelchair, the level of help, anyone riding along, and who pays. Georgia Medicaid asks members for the same core details, plus the Medicaid ID and the type of service, when they book a ride.

### How far ahead do NEMT rides need to be booked?

For Medicaid rides, the broker or plan sets it. Georgia wants 3 business days (manual of July 1, 2026). MTM Health asks for 5 business days in Virginia (for trips from October 1, 2026) and 2 in Wisconsin (September 2026). Illinois fee-for-service wants prior approval requested 7 business days ahead (HFS handbook, March 11, 2024). Discharges and urgent rides are faster everywhere. For private rides, set your own lead time and print it on the form.

### Can a hospital or clinic book a Medicaid ride directly with my company?

Usually not. The facility books with the broker or plan, which assigns the trip. Modivcare in Delaware notes a facility's request for a certain company but may send another one (September 2026). Illinois fee-for-service is different: a transportation provider may ask Transdev for the prior approval itself, at least 7 business days ahead. Run a Medicaid ride only after it is approved and assigned to you.

### Can I require a wheelchair rider to bring an attendant?

No. Federal ADA transportation rules say an entity may not require a person with a disability to be accompanied by an attendant (49 CFR 37.5(e)). Ask whether anyone is coming so you save a seat. Minors are different: Texas Medicaid health plans require a parent, guardian, or authorized adult to ride with members 14 and under, and with members 15 to 17 unless signed consent is presented ahead of time (UMCM 16.4).

### Should the form ask for the rider's diagnosis?

No. Ask how the rider moves and what help they need, not why. If your company is a HIPAA covered entity or business associate, routine requests for health information from a hospital or clinic must be limited to what is reasonably necessary, and you may not ask for a whole medical record unless it is specifically justified (45 CFR 164.514(d)). A broker's own form may ask the type of treatment to approve the ride.

### What if the rider and wheelchair weigh more than my lift can carry?

Refer the ride to a company with bariatric equipment. Lifts on ADA vehicles must have a design load of at least 600 pounds (49 CFR 38.23). You must carry a larger or heavier rider and chair if your lift and van can handle them, but you may decline when the combined weight is over the lift's specifications or carrying it is shown to be unsafe (49 CFR 37.165(b)).

## Official resources

- [HHS: HIPAA for professionals](https://www.hhs.gov/hipaa/for-professionals/index.html)
- [eCFR: 49 CFR Part 37, Transportation services for individuals with disabilities](https://www.ecfr.gov/current/title-49/subtitle-A/part-37)
- [Georgia DCH: NEMT Policies and Procedures (information needed to request a trip, section 811)](https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/Handbooks/Non-Emergency%20Medical%20Transportation%20(NEMT)%20Q3%20-%20July%202026%2020260918170713.pdf)
- [Illinois HFS: Handbook for Providers of Transportation Services (single trip requests, section 207.2.1)](https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/transportationhandbook.pdf)
- [Modivcare: Delaware facility resources and forms](https://www.modivcare.com/facilities/de/)
- [MTM Health: Virginia medical facilities](https://www.mtm-inc.net/virginia/medical-facilities/)