Non-Emergency Medical Transportation (NEMT) Driver Roster transportation 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Transportation Provider name and Facility NPI/UMPI in the designated fields. This information is crucial for identifying your organization.
3. Input today’s date to ensure the form is current. This helps maintain accurate records for submission.
4. For each driver, fill in their name as shown on their license, followed by their Driver’s License number, State of issuance, and Expiration Date. Ensure accuracy to avoid any issues with claims.
5. Record the Employment Start Date for each driver. If a driver is no longer employed, enter their Employment End Date; otherwise, leave this field blank.
6. Finally, have the Transportation Company Owner sign and date the form at the bottom to certify that all listed drivers are validly employed or contracted.

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