Free NEMT driver trip log template
A trip log your drivers fill in on every ride. Print it, or download the CSV and open it in Excel or Google Sheets. Free, no signup.
What a trip log should capture
CMS says every state requires NEMT providers to document, at a minimum, the rider's name and Medicaid ID, the pickup and drop-off locations, the date and time of the trip, and the miles driven with the rider in the vehicle (CMS NEMT booklet for providers). This log covers those and adds the fields states and brokers commonly ask for:
- Trip or authorization number. Many states require trips to be authorized before the ride. Write the number down so each trip matches its authorization.
- Loaded miles. Only the miles with the rider on board. A no-show is not billable, and claiming miles for one is a fraud pattern CMS calls out by name.
- Mobility or assistance. Ambulatory, wheelchair, stretcher, or escort. It shows the level of service matched what the rider needed.
- Driver and vehicle. So you can show the driver was licensed and the vehicle met your state's rules on that date.
- Signature. Some states and brokers require the rider's signature at the end of the trip. If the rider can't sign, a facility staff signature or a written reason in the notes is better than a blank.
- Notes. No-shows, cancellations, wait time, an escort on board, anything an auditor would ask about later.
How to use it
On paper
- Print one sheet per driver per day. Fill in the driver, vehicle, and date at the top.
- One row per one-way trip. A round trip to dialysis is two rows.
- Write in ink. Some states require it, and it holds up better if you're audited.
- Cross out mistakes with one line and initial them. Don't erase or use correction fluid.
- Collect the sheets at the end of each shift and check every row is complete before you bill.
In a spreadsheet
- The CSV has the same fields, with rider name and Medicaid ID, and driver and vehicle, in separate columns so you can sort and filter by them.
- Keep one file per month. Don't delete rows for no-shows; mark them in the notes.
- A spreadsheet can't prove when a row was typed. Keep the signed paper sheet or another record that shows the ride happened.
NEMT driver trip log
This is the sheet that prints. Your browser hides everything else on the page and prints it landscape.
| Date | Trip or auth # | Rider name and Medicaid ID | Pickup address | Pickup time | Drop-off address | Drop-off time | Loaded miles | Mobility / assistance | Driver and vehicle | Rider or facility signature | Notes |
|---|---|---|---|---|---|---|---|---|---|---|---|
When the paper log gets to be too much
A paper log works until you're chasing missing signatures and retyping sheets into a spreadsheet every night. Beridy fills in this log for you: the driver app records the GPS location and time at pickup and at drop-off on every ride, and collects the rider's signature or the reason there isn't one. The record is self-verified by Beridy, not a certified state EVV submission, so check with your state or broker that it meets their requirements.
It costs $0 a month and $0.50 per completed ride. See Beridy for NEMT or create your account. Getting ready for a review? Read how to prepare for a Medicaid NEMT audit.