NEMT standing order form: one page for every repeating ride
A NEMT standing order form sets up a series of repeating rides on one page: the rider and their needs, the treatment site, the weekday grid with chair or appointment times and pickups, the start and end dates, the facility scheduler to call, the authorization number, and a change log. New York and MTM Health in Virginia and Wisconsin limit each approval to three to six months.
On this page
How the form works
A standing order replaces dozens of single bookings with one approval for a repeating pattern, for example dialysis three mornings a week. This form is the one page your office keeps for each series. It holds the pattern, the dates, the approval, and every change made since the first ride.
- Private and facility-paid series. The facility scheduler or the family fills it in, and your office signs off on the price and the pattern.
- Broker and health plan series. The approval comes from the broker or plan, usually requested by the treating provider. Copy the approved details onto this form so dispatch works from one sheet, and keep the approval reference at the top.
- One series per form. Someone with dialysis plus a weekly therapy visit gets two forms, because the dates, contacts, and approvals differ.
For a single appointment, use the trip request form. For how recurring rides run day to day, see our guide to NEMT standing orders.
The template
Series header
| Field | Entry |
|---|---|
| Standing order or series number | |
| Rider name and birth date | |
| Rider phone, plus a backup contact | |
| Treatment type (dialysis, chemotherapy, therapy, day program, other) | |
| Payer (circle): private / facility / Medicaid broker or plan / other | |
| Authorization or approval number | |
| Approved by (broker, plan, or facility) and the date approved |
Weekly pattern
Fill in only the days that repeat. Chair time is the treatment start at a dialysis unit.
| Day | Chair or appointment time | Pickup time | Expected finish | Ride home: fixed time or will-call |
|---|---|---|---|---|
| Monday | ||||
| Tuesday | ||||
| Wednesday | ||||
| Thursday | ||||
| Friday | ||||
| Saturday | ||||
| Sunday |
Locations
| Detail | Pickup | Treatment site |
|---|---|---|
| Name or place | ||
| Street address, unit, or room | ||
| Entrance and where the van stops | ||
| Access notes: gate code, call box, lobby desk | ||
| Phone |
Rider needs for every ride in the series
| Question | Answer |
|---|---|
| Gets around with: nothing / cane / walker / manual wheelchair / power wheelchair / scooter / stretcher | |
| Help level: curb only / door to door / through the door / handed to a named person | |
| Combined weight of rider and chair | |
| Escort or attendant riding each time (names) | |
| Medical necessity paperwork on file (Level of Need, certification, or physician letter): Yes / No | |
| Regular driver and backup driver |
Dates
| Field | Entry |
|---|---|
| First ride date | |
| Last ride date (end of the approval) | |
| Renewal reminder date, two to three weeks before the last ride | |
| Holiday dates when the treatment site changes its schedule |
Facility contact
| Field | Entry |
|---|---|
| Scheduler or charge nurse name | |
| Direct phone and email | |
| Backup contact | |
| Who to call when treatment runs late or the rider is sent to the hospital |
Change log
Record every change, even one-day changes. On Medicaid series, write the approval reference before the change takes effect.
| Date logged | What changed | One day or whole series | Effective date | Requested by | Approval reference | Entered by |
|---|---|---|---|---|---|---|
Sign-off
| Field | Entry |
|---|---|
| Requested by (name, role, organization) | |
| Accepted by (your office) | |
| Date |
What five Medicaid programs require
Medicaid programs agree on the idea and differ on the details. Put your own program’s limits on the form.
| Program | Who may request | Lead time | Length of approval | Other rules |
|---|---|---|---|---|
| New York (MAS) | The enrollee’s medical provider or their staff, through the web portal; not the enrollee, family, or transportation provider | 3 or more business days ahead of the first ride | Up to 6 months per order; the medical office renews it online | Asks for days, times, both addresses and directions, escorts, level of service, treatment type, and a facility contact |
| Illinois fee-for-service (Transdev) | The rider or a representative, your company, or the medical office; sent by fax or through the online portal, never by phone | 7 or more business days before the first service date | One medical necessity form covers a wheelchair van or service car series for up to 180 days | Used when a rider goes to the same site more than three times a month; a new form is needed if the level of transportation changes |
| Delaware (Modivcare) | A caseworker, case manager, nurse, social worker, or other professional directly involved in care | At least 3 days | A standing order is a series of 3 months or more | For treatment three or more days a week; a parent or guardian signs a consent form for a child |
| Virginia (MTM Health) | Medical facilities, by phone or the facility portal | 5 business days for routine requests | Up to 6 months at a time | Covers dialysis, chemotherapy, radiation, infusion, methadone, therapy, wound care, adult day care, and more |
| Wisconsin (MTM Health) | Medical facilities, by phone or the facility portal | 2 business days, like other trips | Up to 6 months for dialysis, 3 months for other treatment | Will-call returns get a vehicle within one hour of the call |
Two points in these rules matter most to dispatch. First, the approval covers one fixed pattern. New York may grant a standing approval for extended treatment when the appointments are at one site and one company does the driving, and a new site or day has to be approved before the ride or the claim may be denied. Second, continuity counts. In Virginia, MTM Health sends recurring trips that are pre-set with a named provider straight to that provider, and asks it to keep the same driver where scheduling allows.
Keeping the series accurate
Keep each series matched to the rider’s real schedule. A series that keeps running after something changes produces rides nobody approved.
- Watch the end date. Rides past the approval’s last day have no authorization behind them. Start the renewal when the reminder date comes up, not after the last ride.
- Pause it during a hospital stay. Tell the broker, plan, or facility that the rider is admitted and hold the upcoming rides. Restart them on discharge. A series left running produces a string of no-shows.
- Ask about holidays early. Treatment sites may shift days around a holiday, so get each site’s holiday schedule weeks ahead. Log each moved day as a one-day change so the weekly pattern stays intact. Our guide to the NEMT holiday schedule covers the planning.
- Separate one-day and permanent changes. A single Wednesday moving to 2 p.m. is not a new chair time. Mixing the two is how a series drifts away from its approval.
- Keep the chair time current. When a unit moves the rider to a different shift, every pickup in the series moves too.
- Match broker trips to the series. When a broker sends dated trips for a pattern you already hold, attach them to the rides on the schedule instead of booking a second copy.
Recurring rides in HealthRide
HealthRide turns the weekly pattern on this form into real rides. Enter the days once and recurring trips are created roughly six weeks out and kept that far ahead, each with a fare from the payer’s rates. A single moved Wednesday stays a one-day edit, you can pause the series for a hospital stay and resume it after, and ending it clears the rides still to come.
Frequently asked questions
- Can riders request their own Medicaid standing order?
- In several programs, no. In New York, MAS accepts standing orders only from the enrollee's medical provider or staff acting for them, such as a nurse, scheduler, or receptionist, and never from the enrollee, family, or a transportation provider. Delaware's Modivcare form has to come from someone directly involved in the rider's care, such as a caseworker, case manager, nurse, or social worker. Illinois fee-for-service lets more people ask, including the rider or someone acting for them, the treating office, and your own company, but medical documentation has to back the level of transportation.
- How long does a standing order stay approved?
- It depends on the program. New York caps each standing order at six months from its start date, and MTM Health books Virginia standing orders for as long as six months per booking. MTM Health in Wisconsin allows six months for dialysis and three months for other treatments. Put the end date and a renewal reminder on the form.
- How early should a standing order request go in?
- Check the program's clock before the first ride. New York wants the request in three business days or more ahead of the first ride. Illinois fee-for-service needs seven business days or more before the first service date and refuses standing requests by phone. Delaware's Modivcare asks for the form three days or more in advance.
- Can I move a rider's standing order to a new day or time myself?
- Not on a Medicaid ride. New York's transportation manual requires the approving office to sign off on a new location or day before the ride happens, and a change made without that sign-off can leave the trip unpaid. Illinois takes changes by phone and issues a new approval number, and Delaware's Modivcare accepts a phone call or a fresh form. Log every change with the approval reference.
- Does a standing order mean the rider gets the same driver?
- Not as a guarantee. MTM Health expects Virginia providers to try in good faith to keep one driver on a recurring series when scheduling allows, and to write down each time someone else drives. Consistency matters most for riders with memory or mobility needs, so name a regular driver and a backup on the form.
- Do stretcher standing orders need extra paperwork?
- Often. For dialysis riders who travel on a stretcher, Georgia requires a medical necessity letter with the standing order request. Illinois asks for the documents that justify the transport level with any standing request. MTM Health in Virginia has the rider's healthcare provider fill in a Level of Need form when a rider needs a stretcher van or help door to door or hand to hand.
