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Non-Medical Transportation
Ohio Medicaid Waivered Services · PASSPORT · MyCare Ohio · Individual Options · Level One Waiver
Month
Year
MCO / Funder
Prior Auth # (PA)
Office Coordinator / Scheduler
| # | Consumer Full Name | Medicaid ID | Date of Service | Pick-Up Address | Pick-Up Time | Drop-Off Address | Drop-Off Time | Odo. Start | Odo. End | Miles | Trip Purpose / Destination Type | Driver Name & Signature | Consumer / Guardian Signature |
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⚠️ Documentation Compliance Notice (Section 8.1 & 8.2)
All trip logs must include the consumer's full name and Medicaid ID, date of service, actual pick-up and drop-off addresses and times, odometer start and end readings, driver name and signature, and consumer or guardian signature confirming transport. Trip logs must be retained for a minimum of 6 years per Ohio Medicaid requirements and must be available for review by the MCO, DODD, ODM, or any authorized auditor upon request. Falsifying trip records is a violation of Ohio Medicaid regulations and may result in termination, repayment of claims, exclusion from Medicaid, and criminal prosecution.
Driver / Submitting Staff Signature
Signature & Date
Supervisor / Coordinator Approval
Signature & Date
Dulla Care Home Healthcare · NMT Trip Log · Ohio Waivered Services · Internal Use Only · Confidential