NEMT driver attestation form: the federal driver checks a company certifies, with a fill-in copy

A driver attestation is the signed page that tells a state, broker or health plan that a driver has cleared the federal minimums for Medicaid rides. Federal law does not set a format, so states, brokers and plans each use their own. The copy below carries the four federal lines plus optional lines that some payers add. What the four minimums mean is explained in the NEMT driver requirements guide, and the other paperwork brokers collect is in broker credentialing. This page is the form and the rules for signing it.

It is also not the trip attestation. That is a separate statement, on each trip record, that the ride happened, and the documentation requirements guide covers it.

Which payers ask for one, and what do their forms look like?

Payers ask in their own words, because the law only requires each state to have “a mechanism, which may include attestation” that its NEMT providers and drivers meet four minimums. CMS’s 2023 transportation guide adds that each state attests in its Medicaid state plan that those minimums are met. States and brokers then collect proof from providers. Four current examples show how much the paperwork differs:

If a payer hands you its own form, sign that one. The form below is the driver-level record behind it, and its Part 2 follows the federal text.

Who signs: the owner or each driver?

Both sign, for different parts. The company’s authorized person signs the certification the payer relies on. North Carolina’s matrix asks for the office administrator, and Modivcare’s page says an individual with the authority to attest to the accuracy and completeness of the information must sign. Each driver signs for the facts only that driver can vouch for, such as convictions and traffic tickets. Modivcare’s roster has each employee sign that training is complete, and it lets each driver return a roster alone.

Indiana’s enrollment adds a duty to list every driver. The provider names each one and attests that all individuals who currently provide transportation have been reported. The form below puts the driver’s signature in Part 4 and the company officer’s in Part 5, so the file shows who stated what.

The form

Complete one form per driver. Strike any Part 3 line your payers do not require. Part 3 comes from real payer paperwork: the felony and violation lines from one Michigan health plan’s form, the training line from Modivcare’s roster, and the background check and driving record lines from the list of driver file contents in MTM’s agreement. The form leaves out the Social Security number that Indiana’s enrollment asks for. Enter it only where a payer requires it.

Part 1: Company and driver

Part 2: The four federal lines

Part 3: Lines your payers add (check only those that apply)

• I have not been convicted, under federal or state law after August 21, 1996, of a felony for the unlawful manufacture, distribution, prescription or dispensing of a controlled substance.
• In the past two years I have not been convicted of more than two moving violations, operating while intoxicated, or driving under the influence.
• I completed [company]‘s code of conduct and compliance training on [date and time] and will repeat it by [date].
• A criminal background check was completed on [date], and a driving record covering [number] years was pulled on [date].
• Other line a payer requires: [text and the payer’s name].

Part 4: Driver’s statement

I confirm that the statements above are true. I understand that [company] relies on them and may give this form to a state Medicaid agency, health plan or broker. I understand that a knowingly false statement can lead to discipline, loss of work on Medicaid trips, and civil or criminal penalties. I will tell [contact] within [number] business days if any line stops being true.

Printed name: ______________________

Signature: ______________________ Date: __________

Part 5: Company certification and renewal

On behalf of [company], I certify that the statements in Part 2 are true for this driver, that the checks shown were made on the dates shown, and that [company] has the processes described in lines 3 and 4.

Name and title: ______________________

Signature: ______________________ Date: __________

Renewal due: __________ (no more than 12 months from the date above)

Keep the signed form in the driver’s file for at least 10 years.

What proof belongs behind each line?

A signed form with nothing behind it proves little, because payers can ask for the file. Modivcare’s attestation says training records go to it on request, without charge. Keep these behind each line:

• Not excluded. The search results with the date and the lists searched. The exclusion screening log holds them, and CMS’s NEMT booklet advises searching before hire and every month after.
• Valid license. A copy of the license and the driving record pull. The yearly driving record review records the pull and the decision. MTM’s agreement asks for a three-year record each year.
• Drug law process. The drug and alcohol policy you wrote, and a signature showing the driver read it.
• Driving history. The same record pulls, plus a note of anything you gave a payer and when.
• Added lines. Training certificates and the background check date. MTM’s agreement has the driver file hold a criminal background check before hire and every year after, drug and alcohol screening results, and training certificates. The driver file checklist lists the rest.

What can a false line cost?

A false line can cost far more than a paperwork correction once the form reaches a payer. Under the federal False Claims Act, a person who knowingly files or relies on a false statement that matters to a false claim owes three times the government’s damages plus a civil penalty for each violation, which is $14,308 to $28,619 for penalties assessed after July 3, 2025 (31 U.S.C. 3729; 28 CFR 85.5). The Act counts deliberate ignorance and reckless disregard as knowing, so signing without checking can qualify, and the government does not have to prove an intent to defraud. The False Claims Act entry explains how a trip bill becomes a false claim.

Two more penalties sit in 42 U.S.C. 1320a-7a. A knowingly false statement of a material fact in an application to enroll as a provider, which reaches Medicaid managed care plans and their providers, carries up to $127,973 per statement. Using a person the company knows or should know is excluded to provide covered services brings a penalty of up to $25,595 for each item or service. Both amounts are the maximums in HHS’s adjustment table as amended January 28, 2026 (45 CFR 102.3).

When should the form be renewed, and what if a line stops being true?

Renew every year and whenever a line changes. Federal law sets no schedule, and payers write their own. Indiana asks for the driver information and attestations at initial enrollment, revalidation and recertification. Its attestation says the provider is responsible for updating the enrollment with additional drivers as needed. Modivcare’s attestation commits the company to tell it right away about any accident, incident or moving violation by one of its drivers or vehicles on Modivcare trips.

When a line stops being true, for example a license is suspended or a search turns up an exclusion match, take the driver off that payer’s trips, tell the payer as your contract requires, and put a dated note in the driver’s file. The steps for a match are in the same screening log page. Then fill in a new form once the line is true again.

Keeping the license line true in HealthRide

Each driver’s credential dates live in HealthRide, and reminders go out before one lapses, so the license on this form does not quietly expire. If someone assigns a driver whose credential has expired, HealthRide flags it on the spot. The office checks credentials and vehicles in fleet management, and drivers work from the driver app.