NEMT trip log template: a free printable log for every ride
A NEMT trip log records each ride as it happens: the rider, the date, pickup and drop-off addresses and times, odometer readings, direct-route miles, the vehicle plate, the driver, the mode of transport, and a signature from the rider or facility. Minnesota lists 14 required elements in statute, and CareOregon's provider manual adds the scheduled pickup time, appointment time, and authorization number.
On this page
How to use this template
The driver fills in the trip log during the shift, at the moment each pickup and drop-off happens. Writing it up at the end of the day from memory is how times get rounded and miles get guessed, and auditors look for exactly that.
- One row per leg. A round trip is two rows: the ride to the appointment and the ride home. Each leg is its own trip with its own times, miles, and signature.
- Who signs. The rider signs at drop-off, or the facility signs to confirm the rider arrived. The driver signs the attestation at the end of the shift.
- Who reviews. Someone in the office checks the log against the manifest before the trips are billed.
- How long to keep it. Keep logs for the longest period your state, broker, or payer requires. CareOregon requires six years after the service. Under 42 CFR 431.107, every Medicaid provider agrees to keep records that show the extent of its services and to hand them over on request.
Print it with the page turned sideways to give each column more writing room. Print one copy per vehicle per day.
A completed row might read, for example: trip 10482, J. Rivera, picked up at 125 Oak St at 9:02 a.m. with the odometer at 48,211.4, dropped off at 400 Main St at 9:24 a.m. with the odometer at 48,218.9, signed by the rider. The odometer shows 7.5 miles for that leg.
The template
Daily header
| Field | Entry | Field | Entry |
|---|---|---|---|
| Company name | Date of service | ||
| Driver name (printed) | Driver ID or provider number | ||
| Vehicle or unit number | License plate | ||
| Mode of transport | Attendant on board (name) | ||
| Shift start time | Shift end time | ||
| Starting odometer | Ending odometer |
Trip entries (one row per leg)
| Trip ID or authorization number | Rider name | Pickup address, time, and odometer | Drop-off address, time, and odometer | Rider or facility signature |
|---|---|---|---|---|
Mileage, wait time, and outcome
Outcome codes: C completed, NS no-show, CD canceled at the door, SR signature requested and not provided.
| Trip ID | Scheduled pickup and appointment time | Billed miles (direct route) | Wait time (minutes) | Outcome code | Notes |
|---|---|---|---|---|---|
Billed miles are measured on the most direct route from pickup to drop-off. Write down how you measured them (odometer, GPS, or a named mapping tool) the first time you use this log, and keep using the same method.
Driver attestation
I certify that this log accurately shows the trips I provided on this date and the actual miles I drove. I understand that false information that leads to improper payment can result in civil or criminal action.
| Driver signature | Date | ||
|---|---|---|---|
| Reviewed by (office) | Date |
What brokers and auditors look for
Auditors check that every billed leg has a record written at the time, by the driver who drove it, with enough detail to prove the ride happened. Minnesota spells this out in statute 256B.0625, subdivision 17b, which lists 14 required elements. That list makes a good standard even if you operate elsewhere.
| What the log must show | Minnesota statute | CareOregon manual |
|---|---|---|
| Rider name and date of service | Required | Required |
| Driver name or provider number | Required | Required |
| Pickup and drop-off addresses | Required | Required |
| Actual pickup and drop-off times | Required | Required, plus scheduled pickup and appointment time |
| Odometer at pickup and at drop-off | Required | Not listed |
| Trip mileage | Direct-route miles and how the route was determined | Required |
| License plate or vehicle ID | Required | Required |
| Mode of transport | Required | Required |
| Authorization or trip number | Not listed | Required |
| Rider or facility signature | Required, or a note that it was refused | Not listed |
| Driver signature and attestation | Required | Not listed |
| Extra attendant’s name | Required when one is used | Not listed |
A few details matter more than they look:
- Legibility. Minnesota requires records written in English and legible to a reasonable person. An unreadable entry counts as a missing one.
- Recovery. Minnesota can recover payment for any trip that is not documented this way, and it applies the rule to audit findings back to January 1, 2020.
- Direct routes. CareOregon lets providers bill only the most cost-effective and reasonably direct route. Extra miles on the log invite a payment adjustment.
- Audit sampling. CareOregon has its brokers verify 5% of all trips both before and after the ride. Audits review the pickup and drop-off times and whether the right level of transport was used.
For the full picture of what payers can ask for, see our guide to NEMT documentation requirements.
Common mistakes
- Round or identical times. Every pickup at 9:00, 10:00, and 11:00 looks invented. Write the minute you arrived and the minute the rider boarded.
- Odometer readings that do not add up. A drop-off reading lower than the pickup reading, or two trips that overlap on the odometer, will fail an audit.
- One line for a round trip. Each leg needs its own row, times, and signature.
- Blank signature lines. If nobody signs, write “signature requested, not provided” with the time. A blank line looks like the ride never happened.
- Billing more miles than the direct route. Minnesota requires providers to take the most direct route, and CareOregon pays only for a reasonably direct one. A detour for fuel or an errand stays off the billed miles.
- Overwriting mistakes. Draw one line through a wrong entry, write the correction next to it, and initial it. Erasing or writing over an entry looks like tampering.
A clean log also makes a broker audit much shorter, because every question already has a written answer.
Keeping the log without paper
In HealthRide, the driver app records pickup and drop-off timestamps, GPS-recorded miles, and on-screen signatures as the driver works each leg. The trip log report shows scheduled versus actual times for every leg and exports as a CSV or a print-ready PDF when a broker asks for documentation.
Frequently asked questions
- How is a trip log different from a manifest?
- The manifest is the plan. Dispatch sends it before the shift with the pickups in order. The trip log is the record of what actually happened on each leg, with real times, odometer readings, and signatures. Keep both, because the log shows whether each trip ran the way the manifest planned it.
- How long should I keep NEMT trip logs?
- Keep them for the longest period any of your rules require. Under 42 CFR 431.107, every Medicaid provider agreement includes a promise to keep records that show the extent of the services provided and to hand them over on request. Brokers and states set the number of years. CareOregon, for example, sets a six-year minimum after the date of service.
- Can I keep my trip log on a phone or computer instead of paper?
- Usually, yes. Minnesota's statute says trip records may be kept in electronic systems or on paper, as long as they can be produced on request. Check your broker contract, since some programs name a specific format for audits.
- What do I do if the rider will not sign?
- Ask the facility to sign instead. Minnesota accepts a signature from the medical provider certifying the rider arrived. If neither the rider nor the facility can or will sign, the driver writes on the log that a signature was requested and not provided. Never leave the line blank without a note.
- Do I still need odometer readings if my vehicles have GPS?
- It depends on your state. Minnesota requires odometer readings at pickup and at drop-off on every trip record. CMS notes that odometer readings or GPS coordinates can be used to calculate mileage when a location has no street address. If your state or broker names odometer readings, record them even when GPS is running.
