Medical transportation quote template for private-pay rides: fares, wait time, validity, and deposit
Overview
A medical transportation quote puts the price of one private-pay ride in writing before the ride runs. It lists each one-way leg with its base fare and loaded miles, the fees that may apply, what is not included, a valid-until date, and any deposit. After the ride, each quoted line becomes a line on the invoice.
On this page
How to use this quote form
A quote is the price of one ride, or one round trip, written for one rider before the ride runs. Your rate sheet is the price list; the quote applies it to a single booking so the rider knows the total before the van arrives.
- Quote every private-pay booking, whether it comes by phone, text, or online request. A short text with the total and the valid-until date helps avoid arguments at drop-off.
- Build the numbers from your rate sheet. If you have no rate sheet yet, start with the trip price calculator and the guide to pricing NEMT trips.
- Check who is paying first. If a broker, a health plan, or Medicaid covers the ride, it is not a private-pay trip, and the private pay guide explains what to do when a private rider turns out to have coverage.
- Keep it with the trip. File the quote with the trip record so the invoice can be checked against it.
The law on how a price must be stated is in all-in pricing for medical transportation. This page is the form.
The quote
Header
| Item | Entry |
|---|---|
| Quote number | |
| Date | |
| Valid until | |
| Prepared by (name, phone, email) |
Who it is for
| Item | Entry |
|---|---|
| Rider’s first name | |
| Person booking or paying, and relationship | |
| Phone or text number for this quote | |
| Payer check | ☐ No broker, health plan, or Medicaid covers this ride |
The trip
List one row for each one-way leg. A round trip is two rows.
| Leg | Date and pickup time | From and to | Level of service, equipment, escort |
|---|---|---|---|
| Outbound | |||
| Return |
The price, leg by leg
| Item | Outbound | Return |
|---|---|---|
| Base fare, including the first ____ loaded miles | $ | $ |
| Added loaded miles (____ miles at $____) | $ | $ |
| Early, late, weekend, or holiday pickup | $ | $ |
| Stairs or stair chair | $ | $ |
| Escort or second crew member | $ | $ |
| Tolls and parking (estimated, receipts on request) | $ | $ |
| Leg total | $ | $ |
Miles are measured from the pickup address to the drop-off address using ____. The same tool is used on the invoice.
Waiting
The first ____ minutes at each stop are free. After that, waiting costs $____ for each ____ minutes. Waiting is not in the totals above unless this line says so: ____.
What this price does not include
- Waiting past the free minutes.
- A stop, a changed address, or a different level of service added after this quote.
- Cancellation or no-show fees under the policy below.
Totals and payment
| Item | Amount |
|---|---|
| Quote total | $ |
| Deposit due now (credited on the invoice) | $ |
| Balance due, and when | $ |
| Payment method | ☐ card on file ☐ pay link ☐ check ☐ cash |
Cancellation
Free until ____ hours before pickup. After that, ____ (amount). Deposit refund terms: ____. See the no-show policy template for wording.
Accepting this quote
Reply “yes” by text or email, or sign below, before the valid-until date.
Name: ____ Signature or reply date: ____
An example, with made-up rates
A daughter books her father’s wheelchair ride to a cardiology office and back. The pickup is at 6:45 a.m., before the company’s 7:00 a.m. start, and his home has 3 steps. The trip is 14 loaded miles each way. The example rates are $55 for a base fare that includes the first 5 miles, $3.25 for each added mile, $15 for a pickup before 7:00 a.m., and $20 for stair help.
| Item | Outbound | Return |
|---|---|---|
| Base fare, first 5 loaded miles | $55.00 | $55.00 |
| Added loaded miles (9 at $3.25) | $29.25 | $29.25 |
| Pickup before 7:00 a.m. | $15.00 | |
| Stairs at the home | $20.00 | $20.00 |
| Leg total | $119.25 | $104.25 |
The quote total is $223.50. Nine added miles at $3.25 is $29.25, and 55.00 plus 29.25 is 84.25 before extras. The valid-until date is 14 days out, and a $50 deposit is due at booking. Waiting at the office is not quoted because the return is booked as a will-call leg, which the rider requests when the appointment ends.
Three checks before you send it
- Who pays. Confirm that no program covers the ride before you quote it. A private quote to a rider whose trip a broker or plan would pay for causes billing trouble later.
- Whether your state sets your price. Connecticut does. Its Department of Public Health sets maximum allowable rates each year for licensed ambulance and invalid coach services, and the regulation says a licensed provider “shall not charge for services which are not specified in the appropriate rate schedule” (RCSA 19a-179-21). The statewide invalid coach schedule for 2026 lists a $172.00 base and $14.78 per mile, and the Department’s 2027 package proposes $177.00 and $15.22 from January 1, 2027. The same rule bars a mileage charge when a ride starts and ends in the same town, and it measures distance from a state mileage docket. A schedule rate is a ceiling, so a licensed wheelchair-van company in Connecticut may charge less, but only for services the schedule lists. Where your state sets rates, build the quote from that schedule. In other states, ask the agency that licenses your vehicles whether it does.
- Where the miles come from. Name the mapping tool or GPS record on the quote and use the same one on the invoice. The rate sheet template has a section on how miles are measured.
Some states also require a consumer price to include every mandatory fee, and a few let a total that depends on distance or time comply by saying what sets it and that it can vary. The form carries all three pieces: the miles line, the waiting line, and the “does not include” list. The all-in pricing guide lists which states and what each requires.
Does a ride quote have to be a good faith estimate?
No federal rule makes a ride quote a good faith estimate on its face. The No Surprises Act rule at 45 CFR 149.610 requires a good faith estimate from a convening provider or facility for an uninsured or self-pay person. It defines a health care provider as a physician or other health care provider acting within the scope of the provider’s license or certification under state law, including a provider of air ambulance services, and a facility as a licensed institution such as a hospital, outpatient department, critical access hospital, or surgery center. Ground transportation companies are in neither list. The estimate that rule requires also carries a disclaimer that it is not a contract, which is the opposite of what a ride quote does: it is a price you stand behind.
If your company holds a health care license, such as a ground ambulance license, ask counsel whether the rule reaches your quotes. CMS’s page on the rule says providers usually must give an estimate if you ask for one or schedule services at least 3 business days ahead, and that a patient can dispute a bill that is at least $400 above the estimate.
Turning the quote into the invoice
Each quoted line becomes an invoice line, so the rider sees the same numbers twice.
- One leg, one invoice line. The invoice template lists each leg with its base, mileage, wait, and extras. Copy the quoted amounts across.
- Change a line only for a named variable. Waiting past the free minutes, an added stop, or a changed level of service can raise a line. Anything else stays at the quoted price.
- Credit the deposit. Show it in the invoice’s adjustments, with the quote number.
- Apply the cancellation terms exactly as quoted. If a leg did not run, the invoice shows the cancellation fee or a zero.
- Keep the quote with the trip record for as long as you keep the invoice.
Quotes from your rate sheet in HealthRide
In HealthRide, the fare for a trip comes from the rate schedule of the payer on that trip and shows when the trip is booked. A family can settle a ride with a pay link or a saved card, and the payment is matched to its trip in one ledger. See invoicing and payments.
Frequently asked questions
- How long should a quote stay valid?
- Pick a window that matches how often you change prices, and print the valid-until date on the quote. A short window suits a company that resets a fuel surcharge often, and a longer one suits a company with stable rates. After the date, quote again from the current rate sheet instead of honoring an old price by default. A rider booking a standing series should get one quote that names the first and last ride dates.
- Is a ride quote a good faith estimate under the No Surprises Act?
- On its face, no. The federal rule at 45 CFR 149.610 covers health care providers acting within their license or certification, air ambulance providers, and licensed facilities such as hospitals and surgery centers. It does not name ground transportation companies. A good faith estimate also has to say it is not a contract. A licensed ground ambulance operator should ask counsel how the rule applies to its quotes.
- Can I charge more than the quoted price?
- Only for items the quote named as variable, such as waiting past the free minutes or a stop the rider adds. Everything else stays at the quoted price. Put every mandatory fee in the quote total, name what sets the miles and the waiting charge, and say that those two can change the amount. The invoice can then follow the quote line by line.
- Does my state set what I can quote?
- In some states it does. Connecticut's Department of Public Health sets maximum allowable rates each year for licensed ambulance and invalid coach (wheelchair van) services, and a licensed provider may not charge for services missing from its rate schedule. The statewide invalid coach schedule for 2026 lists a base of $172.00 and $14.78 per mile, and the Department's 2027 package proposes $177.00 and $15.22 per mile from January 1, 2027. Check your state health or EMS agency before you build quote prices.
- Should I quote a round trip as one price?
- Quote it as two one-way legs, each priced and shown on its own line, with a total at the bottom. A rider can then see what the return costs, a cancelled return is easy to handle, and each leg matches one line on the invoice. This follows the way the rate sheet bills a round trip, as two one-way trips.
- Should I ask for a deposit?
- For a long trip or a rider you have not driven before, yes. Print the deposit amount and its refund terms on the quote, collect it with a stored or one-time card authorization, and show it as a credit on the invoice. Our credit card authorization form covers the consent language. A deposit that the rider cannot get back under any condition should be written as a cancellation fee instead.
