New facility account setup form: billing contacts, who can book, and rates
Overview
A facility account setup form is the one-page record a ride company completes when a hospital, nursing home, or clinic starts booking rides. It captures the facility's legal name and tax status, billing and accounts payable contacts, how invoices are delivered and paid, who may book and cancel, which rides the facility pays for, the rate sheet, privacy terms, and the start date.
On this page
How to use this form
Complete one form for each billing entity, with a row for every campus, unit, or clinic that will book rides. Fill in the first half on a short call with the facility’s scheduling and accounts payable contacts, and the second half once the rate sheet is agreed. The form is the working record that dispatchers and billing staff use every day. The contract itself is the facility transportation agreement, and the pricing sits on the rate sheet.
The reasoning behind the fields is covered elsewhere, so this page stays short. Billing facilities for NEMT rides explains rate schedules, invoice contents, and disputes. How facilities pay invoices covers ACH, checks, and cards. Keeping facility accounts covers the reviews that follow.
The form
A. The account
| Line | Entry |
|---|---|
| Legal name and any “doing business as” name | |
| Facility type | ☐ Hospital ☐ Skilled nursing facility ☐ Assisted living ☐ Dialysis or clinic ☐ Adult day program ☐ Other ____ |
| Tax status | ☐ For-profit ☐ Nonprofit ☐ Government ☐ Federal |
| Parent company or health system, if any | |
| Locations that will book rides | |
| Levels of service the facility will book | ☐ Walking ☐ Wheelchair ☐ Stretcher ☐ Escort ☐ Door-through-door |
| Agreement | ☐ Signed on ____ ☐ Not yet signed |
B. Billing
| Line | Entry |
|---|---|
| Bill-to name and address, if different from above | |
| Accounts payable contact (name, phone, email) | |
| Who approves invoices | |
| Invoice delivery | ☐ Facility supplier portal ☐ Secure email link ☐ Mail |
| Invoice grouping | ☐ One per month for the whole facility ☐ One per unit or cost center ☐ One per resident |
| Purchase order or authorization number | ☐ Not used ☐ Required on every invoice ☐ New one each ____ |
| Invoice frequency | ☐ Per ride ☐ Weekly ☐ Monthly |
| Payment terms | Net ____ days from ☐ invoice date ☐ date received |
| Payment method | ☐ ACH ☐ Check ☐ Card |
| Number to call and confirm any change to bank details | |
| Disputed lines raised within | ____ days of the invoice |
C. Who may book and cancel
| Name | Role | Phone and email | Book | Cancel |
|---|---|---|---|---|
| ☐ | ☐ | |||
| ☐ | ☐ | |||
| ☐ | ☐ | |||
| ☐ | ☐ |
| Line | Entry |
|---|---|
| How the facility requests rides | ☐ Portal ☐ Phone ☐ Online form ☐ Email |
| Notice for scheduled rides | ____ business days. Same-day requests: ____ |
| After-hours and weekend contact | |
| Standing orders | ☐ Allowed, with an end date ☐ Not used |
| Reference on every request | ☐ Facility patient ID ☐ Room and unit ☐ Authorization number |
D. Which rides the facility pays for
| Ride | Who is billed |
|---|---|
| Rides the facility books under the agreement | ☐ Facility |
| Riders whose Medicaid ride program or health plan pays | ☐ Not billed to the facility. Staff book through the program |
| Private-pay residents | ☐ Resident or family ☐ Facility |
| Rides the state counts as part of the facility’s daily rate | ☐ Facility |
E. Rates and terms
| Line | Entry |
|---|---|
| Rate sheet version and effective date | |
| Free waiting time and the charge after it | |
| Cancellation notice and the late fee | |
| No-show rule | |
| Escort, stairs, and after-hours charges |
F. Privacy and paperwork
| Line | Entry |
|---|---|
| Business associate agreement | ☐ Not needed ☐ Signed on ____ |
| What identifies a rider on an invoice | ☐ Facility patient ID ☐ Initials ☐ Name |
| Form W-9 sent | |
| Insurance certificate sent | |
| Facility requirements for drivers | ☐ Badge ☐ Orientation ☐ Immunization record ☐ Background check proof ☐ None |
| Exclusion screening done |
G. Start
| Line | Entry |
|---|---|
| Start date and first ride booked | |
| Account owner at our company | |
| Welcome call to the booking staff done | ☐ |
| First review meeting |
Why some lines are on the form
Most lines explain themselves. These six need a reason.
- Form W-9. The facility needs your taxpayer identification number for its information returns. Under the IRS instructions for requesters, a payer must withhold and deposit 24 percent of reportable payments when a payee fails to furnish one, and it can be liable for any amount it should have withheld and did not. A nonprofit or government facility asks too: the IRS treats nonprofits as engaged in a trade or business for these reporting rules, and payments by federal, state, or local government agencies are reportable. What counts as reportable, and the $2,000 threshold that applies from 2026, is in 1099 forms for NEMT providers.
- Payment method. A card payment is reported on Form 1099-K by the payment processor, not by the facility on Form 1099-NEC or 1099-MISC, so the method decides whose paperwork covers the money. The same 1099 guide shows what each form carries.
- Levels of service. Each level carries its own vehicle and rate, so the facility names the levels it will book and the rate sheet prices each one. How a hospital vets a ride vendor is in becoming a hospital transportation vendor.
- What identifies a rider on an invoice. Invoices carry riders’ names, dates, and destinations. The minimum necessary standard in 45 CFR 164.502(b) asks for reasonable efforts to limit health information to what the purpose needs, and most facilities settle on their own patient ID. The facility billing guide says how to send invoices safely.
- Number to confirm bank details. Payment instructions are a common target of email fraud, covered in how facilities pay invoices. A change to where the facility pays you gets confirmed on the number written here before anyone acts.
- Which rides the facility pays for. Section D keeps a Medicaid rider’s trip from landing on the facility’s invoice. The guide on billing facilities explains why.
An example of a completed account
This is an invented example, not a real customer. A 90-bed nursing home with a parent company that pays every invoice from one office fills the form like this:
- Bill-to. The parent company’s accounts payable team, with the home’s administrator as the person who approves invoices.
- Invoice grouping. One invoice a month for the home, with one line per one-way trip and the resident’s facility patient ID instead of a name.
- Who may book. Two unit clerks and the social worker may book and cancel. The night charge nurse may cancel only.
- Rides the home pays for. Wheelchair and stretcher trips booked under the agreement, and trips for private-pay residents who asked the home to book. Residents whose rides go through the Medicaid ride program are never put on the home’s invoice.
- Standing orders. Dialysis three days a week for two residents, with a review date every 30 days.
Setting up facility accounts in HealthRide
A ride company on HealthRide gives each facility’s staff a portal to request rides, follow the vehicle live, and view and pay invoices. Invoices build from completed trips, priced from the facility’s rates, with due dates set from its terms, and they stay private by default, with rider details shown only for payers the company has approved. Facilities can pay by card with pay links and saved cards. See invoicing.
Frequently asked questions
- What goes on a facility account setup form?
- The facility's legal name, type, and tax status; the bill-to name and accounts payable contact; how invoices are delivered, grouped, and paid; the people allowed to book and cancel; which rides the facility pays for; the rate sheet and its effective date; privacy terms; the paperwork exchanged; and the start and first review dates. The signed agreement stays a separate document.
- Why does a facility ask for my Form W-9?
- The facility needs your taxpayer identification number for its information returns. If a payee does not furnish one, the payer must withhold 24 percent of reportable payments until the problem is fixed (IRS Instructions for the Requester of Form W-9). Send a completed W-9 before the first invoice, with the name and number matching your other records.
- Who should be allowed to book rides for a facility?
- A short list of named people or roles, such as the scheduling desk, case managers, and the charge nurse on nights. Record each person's phone and email and whether they may book, cancel, or both. A request from anyone else goes back to the account contact, which keeps unapproved rides off the invoice.
- Should every ride a facility books be billed to the facility?
- No. A facility often books rides that another payer owns, such as a Medicaid rider whose trip goes through the state ride program or a private-pay resident who pays personally. Mark on the account which kinds of ride the facility pays for, so dispatch and billing treat each booking the same way every time.
- How often should the account form be updated?
- Whenever a billing contact, bank detail, rate sheet, or authorized booker changes, and at each review meeting. Date every version and keep the old ones, so a question about what was agreed in March can be answered from the March form. Confirm any change to bank details on the number written on the form before acting on it.
- What should be settled before the first ride?
- The rate sheet, who may book, where invoices go, the payment terms, whether a business associate agreement is needed, and the W-9 and insurance certificate. Set the first review date at the same time. A signed agreement is better still, and the facility transportation agreement template is built for that.
