Credit card authorization form for NEMT rides
A credit card authorization form is the cardholder's signed permission to charge a saved card for NEMT rides without calling each time. It names the rides covered, how each charge is figured, when the card is charged, any charge if the rider no-shows or cancels late, and how to withdraw consent. It shows only the card's last four digits and never records the security code.
On this page
When you need this form
Use this form whenever you will charge a card later without the cardholder reading the number to you again. Four situations come up in NEMT:
- Repeat private-pay rides, such as a standing dialysis schedule, paid after each trip.
- A family member paying for someone else, where the person holding the card is not in the van.
- Fees charged only when something happens, for example a no-show fee or a late cancellation fee.
- Deposits on long trips, where part of the fare is charged at booking and the rest after the ride.
Rides paid by Medicaid or a broker never go on a card. The program’s payment is the full payment for those rides, so this form does not apply to them.
The form
Section 1: Our business
| Item | Details |
|---|---|
| Company name | |
| Street address where we operate | |
| Phone for billing questions | |
| Email for billing questions |
Section 2: Cardholder
| Item | Details |
|---|---|
| Name as shown on the card | |
| Billing address and ZIP code | |
| Phone and email for receipts and notices | |
| Who the cardholder is to the rider: the rider, family, a facility, or someone else |
Section 3: Rider, if not the cardholder
| Item | Details |
|---|---|
| Rider’s name | |
| I agree that the cardholder may receive receipts showing my ride dates, where each ride started and ended, and the amounts charged | Rider signature: |
Section 4: Card to be charged
| Item | Details |
|---|---|
| Card brand (Visa, Mastercard, American Express, Discover) | |
| Last four digits only | |
| Expiration month and year | |
| How the card was saved | Secure payment link, or entered by staff directly into the payment system |
Do not write the full card number or the security code on this page.
Section 5: What this authorization covers
| Term | Filled in by the company |
|---|---|
| Rides covered | For example: wheelchair rides for the named rider between home and the dialysis center |
| How each charge is figured | Per the rate sheet dated ____, attached |
| When the card is charged | After each completed ride, weekly on ____, or monthly on day ____ |
| Charges set off by an event | No-show fee of $____ when . Late cancellation fee of $ when canceled less than ____ hours before pickup. |
| Deposits | $____ at booking for trips over ____ miles, applied to the final fare |
| Credit card surcharge, if any | ____ percent on credit cards only, never on debit |
| Currency | US dollars |
| This authorization ends | On (date) ____, or when either side cancels it in writing |
Section 6: Changes, cancellation, and refunds
- We will tell you about any change to these terms by ____ (email, text, or mail) at least ____ days before it takes effect.
- You may withdraw this authorization at any time by calling or emailing us at the contact details in Section 1. Charges for rides already completed remain due.
- Refunds for charges made in error are issued to the same card within ____ business days.
- This authorization does not cover any ride paid by Medicaid.
Section 7: Signature
| Item | Details |
|---|---|
| I authorize the charges described above to the card in Section 4 | Cardholder signature: |
| Printed name | |
| Date |
Section 8: Office use
| Item | Details |
|---|---|
| Saved to the payment system by (staff name) | |
| Date saved | |
| Any paper showing card details destroyed on (date) | |
| Copy sent to cardholder on (date and method) |
What the card networks expect
Visa’s April 2026 rules spell out the terms a cardholder must agree to before a merchant stores a card for later charges. Each one has a place on this form:
| What Visa’s rules require | Where it sits on this form |
|---|---|
| The merchant’s location and its address, email, and phone for questions | Section 1 |
| The card to be used, shown by its last four digits | Section 4 |
| A description of the service and how each amount is determined | Section 5, rides covered and rate sheet |
| Timing and frequency of scheduled charges | Section 5, when the card is charged |
| For unscheduled charges, the event that prompts them | Section 5, no-show and late cancellation lines |
| Cancellation and refund policies | Section 6 |
| How the cardholder hears about changes, and when the agreement expires | Sections 5 and 6 |
| The currency of the charges | Section 5 |
| Acknowledgment of any surcharge, where surcharging is allowed | Section 5 |
Three other rules shape how you use it. The card terms must be shown when the cardholder consents and kept separate from your general terms, which is why this is its own page rather than a paragraph in a service agreement. For scheduled repeat charges, you must offer an easy cancellation method and list the fixed dates or intervals of the charges. And you must refund the full amount if you did not follow the terms of the sale.
Keeping card details safe
The safest form is one that never holds a card number. Have the cardholder enter it on a secure payment link, or key it straight into your payment system, and keep only the last four digits on paper.
- Security codes are never kept. The PCI Security Standards Council treats the three- or four-digit code as sensitive data that cannot be retained once the charge it was collected for is authorized. Encryption does not change that, and neither does the customer’s permission. Saved-card and repeat charges work without it.
- Destroy any paper that shows a full number. If a card number was ever written down, shred it once the card is saved, and note the date in Section 8.
- Limit access. Store signed forms where only billing staff can reach them, locked up if on paper and in a restricted folder if scanned.
- Send a copy to the cardholder. They can then check each charge against the terms they signed.
Fees the cardholder agreed to
Every fee that reaches a saved card should be one the cardholder read and accepted before signing. Match the no-show and cancellation lines to your written no-show policy word for word, and use the same amounts as your rate sheet.
Two limits apply no matter what the form says:
- Medicaid members. CMS’s September 2023 transportation guidance bars states and providers from charging members for no-shows. The payment-in-full rule at 42 CFR 447.15 means the member owes you nothing for a covered ride except cost sharing written into the state plan.
- Surcharges. Visa permits a US credit card surcharge of up to 3 percent, never on debit cards, disclosed before payment, and only where state law allows it.
For holds, deposits, and answering a chargeback with this form and the trip record, see card payments for private-pay rides.
Mistakes to avoid
- A blank “any charges” line. Consent to unnamed charges is weak consent. Name every fee and the event behind it.
- The full card number on file. Keep only the last four digits.
- A security code box on the form. Remove it.
- Charging a Medicaid rider. Keep broker and Medicaid rides off saved cards.
- No end date. Put a date or “until canceled in writing” in Section 5.
- Rate changes without notice. Tell the cardholder before new rates reach the card.
Saved cards in HealthRide
With HealthRide, a rider or facility can pay by card, using a pay link or a card on file, through a secure card processor, so your office never needs card numbers on paper. Card payments, refunds, checks, and cash all land against the right invoice in a single ledger. See payments, and the invoice template for what each charge should itemize.
Frequently asked questions
- What should a card authorization form for rides include?
- Your business name, location, and contact details; the cardholder's name; the card's last four digits; the rides it covers; how each charge is calculated; when charges happen; any fee triggered by an event, such as a no-show; how you announce changes; when the permission ends; and your cancellation and refund terms. Visa's rules call for the cardholder's express informed consent to terms like these before a card is stored.
- Can I keep the three-digit security code on file?
- No. Under PCI Security Standards Council guidance, a card verification code cannot be kept once the charge it was collected for is authorized, even encrypted and even with the customer's permission. Saved-card and repeat charges do not need the code. Leave the field off your form entirely.
- Can I charge the saved card for a no-show?
- Yes for private-pay riders, as long as the signed form states the fee and defines a no-show. Visa's rules require that charges triggered by something happening, instead of on set dates, name the trigger in the agreement. A Medicaid member is different: CMS guidance from September 2023 rules out no-show charges to members by states and providers alike.
- Does the cardholder have to be the rider?
- No. An adult child, a spouse, or a facility can pay. Have the cardholder sign the authorization, and have the rider sign the line that lets you share ride dates and places with the payer. For HIPAA-covered companies, 45 CFR 164.510(b) limits what a family member may receive to information that bears directly on their role in the rider's care or its payment.
- How long should I keep a signed authorization?
- For the full time the authorization is in force, at minimum. Visa requires merchants to keep the agreement terms on file for the life of the agreement and to provide them to the cardholder or issuer when asked in writing. Keep the signed page afterward with the invoices and trip records for the charges made under it.
- Can I add a surcharge for paying by credit card?
- Visa allows it in the US only on credit cards, never debit, and caps it at 3 percent, subject to state law. The surcharge must be disclosed before payment and cannot exceed your merchant discount rate for Visa credit card sales. If you surcharge, say so on the authorization form, since the consent itself has to acknowledge any surcharge.
- Will an HSA or FSA card cover a ride?
- It can, but the rider's plan and card decide. IRS Publication 502 treats a ride as a medical expense when reaching medical care is its main purpose and the ride is essential to that care. Whether the card accepts the charge, and what proof the plan asks for later, depends on the plan. Give the rider an itemized receipt with dates and amounts, and leave diagnoses off it.
