NEMT Trip Manifest

Daily non-emergency medical transportation trip manifest for drivers to record each trip’s pickup and drop-off times, mileage, mobility type, passenger signature, and billing details.

Trip and Driver Details

• Trip Date
  Date the trip occurred.
• Driver Name
  Driver completing the manifest.
• Vehicle ID or Unit Number
  Internal vehicle identifier used for dispatch and billing records.
• Trip ID
  Unique trip reference number from dispatch or scheduling.

Passenger and Trip Route

• Passenger Name
  Passenger name as listed on the trip assignment.
• Pickup Location
  Pickup address or facility name.
• Drop-off Location
  Destination address or facility name.
• Trip Type
  Select the trip pattern that applies.

Trip Timing and Mileage

• Pickup Time
  Time the passenger was picked up.
• Drop-off Time
  Time the passenger was dropped off.
• Odometer Start
  Vehicle odometer reading at pickup.
• Odometer End
  Vehicle odometer reading at drop-off.
• Total Mileage
  Calculated trip mileage for billing support.

Mobility Assistance and Service Notes

• Mobility Type
  Select the passenger mobility type used for transport.
• Specify Other Mobility Type
  Shown only if 'Other' is selected.
• Assistance Provided
  Select all assistance types provided during the trip.
• Service Notes
  Brief notes for exceptions, delays, no-shows, or billing clarification. Do not include unnecessary PII.

Passenger Signature and Attestation

• Was the passenger able to sign?
  Select whether a passenger signature was obtained.
• Passenger Signature
  Passenger acknowledgment of trip completion.
• Reason Signature Was Not Obtained
  Explain why the passenger could not sign and who, if anyone, provided alternate verification.