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

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 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), so never quote a Medicaid member a private price for a covered ride. 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, 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, and copy the level of help and the notes exactly.
7. File it with the trip record. Keep the form with the trip log 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 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). 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)).
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)).
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, and bariatric transportation. Returns are covered in 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. For the necessity paperwork brokers ask for, see medical necessity form.

Rules the form follows

Rider rights under the ADA

The federal ADA transportation rules in 49 CFR 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)). 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.
• 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 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)).
• 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)). 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)). 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 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. Never charge a Medicaid member for a no-show. CMS says states and providers may not (SMD 23-006, September 28, 2023).