Service agreement template for hospitals, nursing homes, and clinics that book rides

How to use this template

Fill in the blanks, attach the rate schedule (Schedule A) and the contact list (Schedule B), and have a lawyer licensed in your state review the result before anyone signs. The clauses are written in plain English so a facility’s transportation coordinator and its contracts office can both follow them.

• One agreement per facility or health system. A hospital system with several campuses can sign once, with each campus listed in Schedule B.
• Prices live in Schedule A. Build it from your rate sheet so a rate change means swapping one page, signed by both sides.
• Match your other documents. The no-show terms should read the same as your no-show policy, and invoices should follow the invoice template.
• Delete what does not apply. A clinic that books ambulatory rides twice a month does not need the evacuation clause or the stretcher lines.

For finding and pitching facilities, see how to get facility contracts. This page is the paperwork that follows.

The agreement

1. Parties and term

1.1 This agreement is between ____ (“Provider”), located at ____, and ____ (“Facility”), located at ____.

1.2 It starts on ____ and runs for one year. It then renews for one-year terms unless either party gives written notice at least ____ days before a term ends.

2. Services

2.1 Provider will transport Facility’s patients or residents (“riders”) to and from appointments, discharges, and other trips that Facility requests, within this service area: ____.

2.2 Provider offers these levels of service:

2.3 Service hours are ____. After-hours, weekend, and holiday service is available ____.

2.4 Drivers provide transportation and passenger assistance only. A rider who needs clinical care or monitoring during the trip is sent by ambulance.

3. Booking rides

3.1 Only the staff roles or people listed in Schedule B may book, change, or cancel rides.

3.2 Each request states the rider’s name and Facility ID, the service level needed, wheelchair or other equipment, whether an escort rides along, pickup and drop-off locations (with unit or entrance), appointment time, the return plan, and who is paying for the ride.

3.3 Routine rides are booked by ____ on the business day before. Same-day requests are accepted when a vehicle is available, and Provider confirms or declines within ____ minutes.

3.4 Repeat appointments, such as dialysis, may be booked as a standing order that runs from a first ride date to an end or review date.

3.5 Provider confirms each booking by ____ (email, portal, or phone).

4. Pickups, waiting, and returns

4.1 Provider arrives within a pickup window of ____ minutes before to ____ minutes after the scheduled time.

4.2 The rider is waiting at the agreed entrance at pickup time, along with any discharge papers, belongings, and equipment the rider needs.

4.3 The first ____ minutes of waiting are included. Waiting after that is charged under Schedule A.

4.4 Return rides without a set time are booked as will-call rides. Provider picks up within ____ minutes of the call.

4.5 At the destination, Provider hands the rider to ____ when door-through-door service is booked.

5. Cancellations and no-shows

5.1 Facility may cancel without charge until ____ hours before pickup.

5.2 A later cancellation, or a trip where the vehicle arrives and the rider cannot travel, is charged under Schedule A. Before leaving, the driver waits ____ minutes and calls ____.

5.3 If Provider misses a pickup or arrives more than ____ minutes after the window, that leg is ____ (not charged, or credited at ____).

5.4 No cancellation or no-show fee is ever charged to a rider covered by Medicaid.

6. Rates

6.1 Facility pays the rates in Schedule A. Schedule A is fixed before the term starts, reflects fair market value, and does not change with the volume or value of any referrals or other business between the parties.

6.2 Rates change only by a written amendment signed by both parties, with at least ____ days’ notice.

6.3 Provider bills each ride under this agreement to Facility alone, never also to Medicaid, Medicare, another insurer, or the rider. Rides another payer covers are booked under that payer’s rules, not this agreement.

7. Invoices and payment

7.1 Provider invoices ____ (weekly or monthly), with one line per one-way leg showing the date, Facility’s reference number, rider ID, service level, both addresses, loaded miles, and charges.

7.2 Facility pays each invoice within ____ days of its date, by ____ (check, bank transfer, or card).

7.3 Facility raises any question about a specific line in writing within ____ days and pays the undisputed lines by the due date.

7.4 Late payments carry ____ (a charge stated here, only where lawful, or none).

7.5 Before the first invoice, Provider sends Facility a Form W-9 and its current insurance certificate.

8. Drivers, vehicles, and standards

8.1 Provider’s drivers hold valid licenses, pass the background and driving record checks that law and Provider’s policy require, and are trained in passenger assistance and wheelchair securement, plus ____.

8.2 Provider’s vehicles are registered, insured, and maintained. Wheelchair vehicles have a lift or ramp in working order, plus a securement system at each wheelchair position.

8.3 Provider employs or contracts its own drivers and is solely responsible for their pay, taxes, and supervision.

8.4 On request, Provider reports each month on completed trips, on-time pickups, and incidents.

8.5 The parties meet every ____ (for example, each quarter) to review on-time performance, complaints, and open issues, and to agree on fixes.

9. Insurance and indemnity

9.1 Provider carries at least $____ per accident in commercial auto coverage, at least $____ in general liability, workers’ compensation at the levels state law sets, and ____. Facility added as an additional insured: ☐ yes ☐ no.

9.2 Provider sends insurance certificates when this agreement is signed and again whenever a policy renews, and tells Facility of any cancellation or reduction in coverage.

9.3 Each party is responsible for claims arising from its own negligence or its staff’s, and will defend and indemnify the other party against those claims.

10. Rider privacy

10.1 Each party protects rider information and uses it only to arrange, provide, and bill for rides under this agreement.

10.2 Facility shares only the information Provider needs to carry out each ride safely.

10.3 If either party determines that HIPAA requires it, the parties sign the business associate agreement in Schedule C.

10.4 Each party tells the other within ____ days of learning of any unauthorized use or disclosure of rider information.

11. Compliance

11.1 Each party states that neither it nor anyone working on this agreement is on the federal exclusion list. Each screens its staff against that list at hire and every ____ after, and tells the other party within ____ days of any exclusion.

11.2 Nothing of value is offered, paid, or received under this agreement in return for referrals of riders covered by Medicare, Medicaid, or any other federal health care program.

11.3 Provider holds every license and permit its state requires for these services.

12. Incidents and emergencies

12.1 If a rider’s condition becomes an emergency on the way, 911 is the driver’s first call.

12.2 Provider notifies Facility’s incident contact within ____ hours after a crash, injury, fall, or complaint involving a rider, and sends a written report within ____ days. See the incident report template.

12.3 (Optional) Evacuation support. When Facility activates its emergency plan, Provider will try to supply up to ____ wheelchair and ____ ambulatory vehicles within ____ hours, at Schedule A rates, subject to its other commitments.

13. Records

Provider keeps trip records, including times, miles, and signatures, for ____ years and gives Facility copies on reasonable request.

14. Ending the agreement

14.1 Either party may end this agreement without cause on ____ days’ written notice.

14.2 Either party may end it on ____ days’ written notice for a material breach that is not fixed within that time.

14.3 Either party may end the agreement immediately if the other is placed on the federal exclusion list or loses a license or insurance this agreement requires.

14.4 Facility pays for rides completed through the end date. Rider information is returned or destroyed as Schedule C requires.

15. General terms

This agreement, with its schedules, is the complete agreement between the parties. Changes must be in writing and signed by both parties. Neither party may assign it unless the other agrees in writing. The law of ____ governs it. Notices go to the contract contacts in Schedule B. A signed electronic copy has the same effect as a signed original.

16. Signatures

Schedule A: Rates

Effective date of this schedule: ____

Schedule B: Contacts

Schedule C: Business associate agreement

Attach the signed agreement if one is required. The section on business associate agreements below lists the terms federal rules require it to contain.

Pricing terms that keep both sides safe

Price facility rides the same way whether or not the facility also sends you Medicaid or Medicare riders. Two federal sources explain why.

The safe harbor for personal services contracts in 42 CFR 1001.952(d) protects payments for services when the arrangement meets all of its standards:

1. It is set out in writing and signed by the parties.
2. It covers every service provided during the term and specifies them.
3. The term is at least one year.
4. The method for setting pay is fixed in advance, consistent with fair market value in arm’s-length dealings, and not based on the volume or value of referrals or other business payable by a federal health care program.
5. The services do not involve promoting anything that breaks state or federal law.
6. The services contracted for do not exceed what is reasonably necessary for a commercially reasonable purpose.

Clauses 1.2, 6.1, and 11.2 of the template track those standards. The facility’s compliance team decides how its own arrangements fit.

The HHS Office of Inspector General adds a warning in its November 2024 compliance guidance for nursing facilities. It calls the practice “swapping”: a facility accepting a low price on services it pays for itself in return for steering other federal program business to the same supplier. Below-cost deals, and prices lower than you give similar-volume customers without federal referrals, are among the examples it treats as suspect. The facility billing guide explains how this plays out on invoices.

Business associate agreements

A business associate, under the HIPAA definitions in 45 CFR 160.103, creates, receives, keeps, or sends patient information on a covered entity’s behalf for functions such as billing or claims processing. The definition carves out one case: a treating provider that a covered entity sends information to about the patient’s treatment. Whether a transportation company falls inside or outside that line depends on the arrangement, so the facility’s compliance team and your lawyer should decide.

When a BAA is signed, 45 CFR 164.504(e) requires it to:

• State how the business associate may use and disclose the information, and bar any other use.
• Require appropriate safeguards, including the Security Rule for electronic records.
• Require reports of any unauthorized use or disclosure, including breaches.
• Bind any subcontractor that handles the information to the same limits.
• Make the information available for the patient’s access, amendment, and accounting of disclosures.
• Open the associate’s practices and records on this information to HHS.
• Return or destroy the information when the contract ends, where feasible.
• Let the covered entity end the contract if the associate breaks a material term.

A business associate that discovers a breach must notify the covered entity without unreasonable delay, and no later than 60 calendar days after discovery (45 CFR 164.410). Clause 10.4 lets the two parties agree on a shorter window between themselves. Our guide to HIPAA for NEMT providers covers the rest of the privacy rules.

Terms certain facilities must have in writing

PACE organizations. Under 42 CFR 460.70, a PACE organization needs a written contract with every outside organization that furnishes services it does not provide directly. Each such contract identifies the contractor, lists the services with a work schedule where one fits, states what the organization pays and how, and records the start and end dates plus the process for extending, renegotiating, or terminating it. In it, the contractor promises five things: to furnish only services the PACE interdisciplinary team authorizes; to treat the organization’s payment as payment in full and bill no participant, CMS, state agency, or private insurer; to hold CMS, the state, and participants harmless if the organization fails to pay; to seek written approval before assigning the contract or delegating its duties; and to file the reports the organization asks for. Add those promises as a rider to this template. More in PACE transportation.

Nursing homes. Federal rules require a nursing facility to help residents make dental appointments and to arrange transportation to and from them when needed or requested (42 CFR 483.55). Their emergency plans must also cover safe evacuation, including transportation (42 CFR 483.73). OIG’s guidance tells facilities that contract for emergency transportation to confirm the company has enough capacity to move residents safely and on time in a disaster that affects a wide area. Promise only the vehicles you can actually send in clause 12.3.

Signing and keeping it current

Under the federal E-SIGN Act (15 U.S.C. 7001), a contract affecting interstate commerce keeps its legal effect when it is signed or kept in electronic form. A signed PDF or an e-signature platform works.

Put three dates on your calendar each year: the renewal notice deadline in clause 1.2, the Schedule A review, and new certificates of insurance. Run the exclusion checks in clause 11.1 on the schedule you agreed to, using the OIG’s List of Excluded Individuals/Entities. Keep the signed agreement with its schedules and amendments, filed with the facility’s invoices and trip records.

Facility accounts in HealthRide

In HealthRide, facility staff request rides, follow the vehicle live, and view and pay invoices in their own portal. Each facility’s invoices are built from completed trips, priced from its rates, with due dates set by its terms. HealthRide is HIPAA compliant, and each person sees only what their role allows. See invoicing.