Does this agreement work for riders on Medicaid?

No. For a covered ride, 42 CFR 447.15 makes what Medicaid pays, plus any cost sharing in the state plan, the whole payment, and CMS guidance from September 2023 bars states and providers from charging a beneficiary for a no-show. Keep Medicaid and broker rides on the program's own paperwork, and use this agreement only for rides that someone pays you for directly.

Who should sign when an adult child books rides for a parent?

Each person signs in their own role. The rider signs for themselves when able to. When they cannot, a person with a power of attorney signs as agent and writes the capacity beside the name, for example "Juan Doe, as agent for Martina Roe," and you keep a copy of the document. A relative who agrees to pay signs separately as the payer, so the form shows who owes the bill.

Can the agreement require an escort or attendant?

No. The DOT rule at 49 CFR 37.5(e) says an entity shall not require an individual with a disability to be accompanied by an attendant. A rider may choose to bring a family member or aide. DOT's guidance does let you require an attendant as a condition of service you could already lawfully refuse, such as after violent conduct.

Does a rider get three days to cancel an agreement signed at home?

It can happen. The FTC Cooling-Off Rule covers a sale of consumer services made at the buyer's home when the seller's representative personally solicits it and the price is $25 or more. The buyer may cancel until midnight of the third business day, and the contract cannot waive that right (16 CFR 429.0 and 429.1). A sale made entirely by mail or telephone is outside the rule. Ask a lawyer how it applies to your rides.

Is a typed or tapped signature good enough?

In general, yes. For a transaction affecting interstate commerce, the federal E-SIGN Act (15 U.S.C. 7001(a)) bars denying a signature, contract, or record legal effect only because it is electronic. Keep a record of who signed and when, and send the rider a copy they can keep.

Can I add a liability release to this agreement?

This form leaves one out on purpose. The guide to liability waivers for NEMT riders covers what courts have and have not accepted, and a release is the clause to have a lawyer in your state draft.

Private Pay Medical Transportation Agreement Template

Q: How do I change my rates without rewriting the agreement?

The agreement points to the rate sheet by its date, so a new rate sheet with a later date can replace the old one once the notice period in the agreement has passed, if your lawyer agrees that notice is enough in your state. Send it in writing before it takes effect. The card form is a separate document with its own change-notice line, so update it as well when a new charge will reach a saved card.

How to use this agreement

This is the master contract for riders who pay you directly or whose family pays. It says who the parties are, what a ride includes, and how the other documents fit. The pricing, the cancellation terms, and the card terms stay in their own documents, and the agreement points to them. The private pay NEMT guide covers who books these rides and what to charge.

Attach three documents instead of copying them. Prices come from your dated rate sheet. Waiting time, notice, and fees come from your no-show policy. A card to be charged later gets its own card authorization form, because Visa’s rules require the terms for a stored card to be displayed separately from your general purchase terms.
One agreement per rider. Name the rider even when a relative pays, and name the payer in their own line.
Never for Medicaid rides. Under 42 CFR 447.15, a provider accepts what Medicaid pays, plus any cost sharing the state plan sets, as the whole payment. Charging Medicaid patients for transportation covers the narrow cases where a separate charge is allowed.
Unpaid balances. Clause 10 lets you stop booking after written reminders. The past-due invoice letters are those reminders.
Send it when the ride is booked. The rider or family can read it at home, and the first ride does not start with a clipboard.
No release of liability. This form records what you will do and what the rider agrees to. A release is a separate decision, covered in the guide to liability waivers for NEMT riders.

Fill in each bracket and have a lawyer in your state review the finished form. It is a starting document, not legal advice.

The agreement

[Company name] rider agreement

Agreement date: [date]. This agreement covers rides paid for by the rider, a relative, or another person named below. It does not cover rides paid for by Medicaid, a health plan, or a broker.

Part 1: The people

Item	Details
Rider’s name, address, and phone
Payer, if not the rider: name, relationship to the rider, phone, and email
People we may call or text about the rider’s rides
Contact for billing questions at [Company name]

Part 2: The terms

1. The rides. We provide [ambulatory / wheelchair / stretcher] rides, [curb-to-curb / door-to-door / door-through-door]. Rides are booked by [phone or online] at least [number] hours ahead. Standing rides run on [days and times] until [date] or until either of us ends them.

2. Prices. Every ride is priced from our rate sheet dated [date], attached as Attachment A. We give the price before the ride is booked and charge that price unless the trip changes, for example by a longer route, an added stop, or a longer wait. We tell the payer in writing at least [number] days before any rate change takes effect.

3. Paying. The payer pays [after each ride / weekly / monthly] by [card, pay link, check, or bank transfer]. We send invoices by [email, text, or mail], and they are due [on receipt / within number days].

4. Cancellations and missed rides. Our no-show and late cancellation policy dated [date], attached as Attachment B, sets how long the driver waits, how much notice a cancellation needs, and the only fees that can apply. We charge no fee for a reason the policy lists as waived.

5. Paying by card. A card is charged later only under a separate card authorization signed by the cardholder, attached as Attachment C. This agreement alone does not permit any card charge.

6. Riding along. A family member or aide may ride with the rider when there is room. We do not require an escort. [If you provide escorts: An escort we provide is booked in advance and priced on the rate sheet.]

7. What the driver does. The driver helps with [list: the vehicle, the lift or ramp, the securement, the door]. The driver will not [list: carry a rider on stairs, give medicine, lift a rider from a bed]. A wheelchair is secured with the vehicle’s securement system on every ride, and every rider uses the seat belt or restraint the vehicle provides.

8. The rider’s information. The rider, or the person signing for them, has given us accurate information about the mobility device, its weight with the rider, oxygen, and the steps at each address, and will tell us when any of it changes. We use it to plan, perform, and bill rides, and share it only with the people named in Part 1 and with the clinic or facility when the ride requires it.

9. Messages. We text ride reminders and a link to follow the driver to [phone number]. Tell us to switch to calls or to stop at any time.

10. When we may decline or end service. We may decline a ride or end this agreement when a rider’s conduct is violent, seriously disruptive, or illegal, when a rider poses a direct threat to the health or safety of others, or when invoices stay unpaid after we have sent written reminders. We do not decline a ride because of a disability, or because of appearance or involuntary behavior that may offend or annoy others.

11. Other coverage. If Medicaid or a health plan may pay for a ride, tell us before booking. We bill them, and we do not charge you for a ride they cover. If coverage is found after you paid for a covered ride, we [refund or credit] the amount within [number] days.

12. Problems. Tell us about a complaint at [phone and email]. We answer within [number] business days.

13. Changes and ending. Either side may end this agreement by telling the other in writing, and rides already given remain payable. A change to this agreement takes effect only when both sides sign it or when we give [number] days of written notice.

Part 3: Signatures

Who	Name	Signature	Date
Rider
Person signing for the rider, if the rider cannot. Capacity: power of attorney dated [date], guardian, or other (describe)
Payer, if not the rider
[Company name], by (name and title)

Copies given: [date and how]. Attachments: A, rate sheet dated [date]. B, no-show and late cancellation policy dated [date]. C, card authorization, if used.

Who signs, and in what role

Three roles can appear on one agreement, and each signs for their own part. The rider signs for themselves when they can. A person acting for the rider signs as that person’s agent. A relative who agrees to pay signs as the payer.

An agent under a power of attorney. The CFPB’s guide for agents says an agent’s authority is strictly limited to what the document and state law allow, and that an agent signs to show the capacity, for example “Juan Doe, as agent for Martina Roe,” never just the rider’s name. Ask for a copy of the power of attorney, read what it covers, and keep the copy with the agreement.
A relative who pays. A son or daughter who books and pays signs as the payer on their own line. That records who agreed to pay, so a person who only arranged the rides is not treated as the payer by default. How to get private pay NEMT clients covers asking who pays on the first call.
Who gets ride information. For a company covered by HIPAA, 45 CFR 164.510(b) lets you share what is relevant to a person’s involvement in the rider’s care or payment with the family or friends the rider identifies, when the rider agrees or does not object. Under 45 CFR 164.502(g), a person with authority to make health care decisions for an adult is treated as the rider’s personal representative. The list in Part 1 records the rider’s choices, and HIPAA and family members explains the two cases. A rider who wants a family member to book and hear details signs the HIPAA authorization form.

Signing at the rider’s home, by phone, or online

How the agreement is signed can matter as much as what it says.

At the rider’s home. If your representative personally solicits the sale and the rider agrees at home, the FTC’s Cooling-Off Rule may apply. The rule covers consumer services with a total price of $25 or more at the buyer’s residence, and it gives the buyer until midnight of the third business day to cancel (16 CFR 429.0 and 429.1). You must give a completed copy of the contract and two copies of a notice of cancellation, in the language used in the sales talk, and the contract cannot waive the right. A sale made entirely by mail or telephone, with no other contact before the service starts, is outside the rule, and so is one made after the buyer visits your business to negotiate. Whether per-ride pricing meets the $25 total is a question for your lawyer.
On paper at your office, or by phone and mail. These generally fall outside the rule and leave a clean record. Ask the rider to take the form home before the first ride.
Online. A rider can sign on a screen. The E-SIGN Act’s general rule, 15 U.S.C. 7001(a), applies to transactions affecting interstate commerce and says electronic form alone cannot make a signature or contract invalid. Keep who signed, when, and the copy you sent back. Electronic signatures for NEMT covers the trip-log side.

What the agreement may ask of a rider with a disability

A private company that sells rides to the public is covered by the DOT’s ADA transportation rules, which call this “specified public transportation” (49 CFR 37.3 and 37.21), and several of those rules reach clauses above. Each of these is a drafting limit, not a reason to leave the clause out.

Securement (clause 7). You may require that a wheelchair be secured (49 CFR 37.165(c)(3)). You may not deny a ride because the vehicle’s securement cannot hold the device satisfactorily (37.165(d)). Asking a rider to move to a vehicle seat is allowed only as a suggestion (37.165(e)).
Weight (clause 8). You may decline a wheelchair and rider whose combined weight exceeds the lift’s specifications, or whose carriage is shown to conflict with legitimate safety requirements (37.165(b)(1)). That is why the form asks for the weight with the chair.
Escorts (clause 6). An entity may not require that an individual with a disability be accompanied by an attendant (37.5(e)). DOT’s guidance does let you require one as a condition of service you could already lawfully refuse.
Declining service (clause 10). Refusal is not discrimination when a rider engages in violent, seriously disruptive, or illegal conduct or poses a direct threat. It is discrimination when the reason is appearance or involuntary behavior that annoys others (37.5(h)).
Prices (clause 2). DOT’s guidance to 37.5(d) treats a higher price for the same or comparable service, because the rider has a disability or needs a lift-equipped van, as a special charge. Its example is a $20 shuttle ride that cannot become $40, and it says the same of an extra fee to stow a folding wheelchair when luggage is stowed for less. Rate sheets that price by level of service or list per-ride add-ons are common, so have a lawyer read yours with that guidance beside it.

The guide to refusing a ride covers how these rules play out at the curb.

Keeping it current

Review the agreement once a year and whenever your rate sheet or policy changes. Because the agreement refers to its attachments by date, a new rate sheet or policy can replace the old one after the notice period in clause 2 or 13, without a new signature on the agreement, if your lawyer agrees that notice is enough in your state. Send the new attachment in writing before it applies, and keep the old one in the file with its dates. A price increase notice covers what to say when rates go up.

Where HealthRide fits

In HealthRide, wheelchair, stretcher, and oxygen needs are matched to the van sent. Families can book rides online and follow the driver live from a link sent by text. Payment can be made by card from a pay link or with a saved card, and when a rider does not come out, the driver’s wait is recorded with times, which is the record your cancellation terms rest on. See payments.

Private-pay rider agreement: fares, cancellations, and card terms signed once, before the first ride