The Modivcare standing order form lets a medical facility set up recurring non-emergency transportation for a Medicaid patient in a single submission, rather than booking each ride by phone. You use it when the patient has appointments at the same location at least three times a week for 12 or more weeks — dialysis is the most common case, but behavioral health, substance abuse treatment, and adult day care also qualify. Submit it through the Facility Services web portal or by fax to your state’s Modivcare intake number, and plan on recertifying every three months.
Who Qualifies for a Standing Order
Modivcare defines a standing order as appointments recurring at least three times per week for a period of 12 or more weeks.1Modivcare. How to Access Routine Transportation A Resource for South Carolina Healthy Connections Members The schedule has to stay the same for at least 90 days; any changes during that window can result in the order being denied.2Modivcare. Standing Order Form The form itself lists dialysis, substance abuse treatment, mental health services, and adult day care as qualifying treatment types.
A healthcare provider also has to confirm the patient has a legitimate need for the service, meaning the patient cannot safely drive or use public transit to reach the appointment. If the patient’s schedule is irregular, or if trips are one-off, book them individually through Modivcare’s reservation line instead of using this form.
What the Form Asks For
Regional versions of the form differ slightly in layout, but they collect the same core information. You can download your state’s version from modivcare.com/facilities or fill it in directly through the Facility Services web portal at facility.modivcare.com.3Modivcare. Facility Services Web Portal User’s Guide
Member Information
Enter the patient’s full legal name, date of birth, gender, insurance type, and insurance ID number exactly as it appears on their Medicaid or managed-care card. A single transposed digit in the ID number will prevent the system from matching the request to a valid member and will bounce the form back.4Modivcare. Dialysis Standing Order Form
Schedule
Check the days of the week the patient needs transport, then enter both the appointment time and the return pickup time. Both times are required, because the system uses the return time to dispatch a vehicle back to the facility. Enter the start date, and either a specific end date or a check in the “Ongoing” box.
If you are submitting through the online portal, the start date must be at least five business days after the current date to allow for processing.3Modivcare. Facility Services Web Portal User’s Guide Paper and fax submissions should build in the same lead time.
Pick-Up and Drop-Off
Give the full address, facility or building name, and phone number for both the pick-up location (usually the patient’s home) and the drop-off location (the treatment center). Note any apartment access codes or gated-community instructions under Special Needs. Drivers are not permitted to enter a patient’s home or go beyond the main entrance of an apartment building, so the pick-up point should be the main door or lobby.5Modivcare. Florida Generic Transportation Guidelines
Height, Weight, and Signature Status
Height and weight are used to assign a vehicle that can physically accommodate the patient, and there is a bariatric checkbox under the wheelchair and stretcher categories for patients who need oversized equipment.6Modivcare. Medical Necessity Form Documentation Guidelines Two yes-or-no questions ask whether the patient can sign the driver’s log at pick-up and drop-off, and whether that status is permanent. If the patient cannot sign, the driver follows an alternate verification process.
Treatment Type
Check the box that matches the patient’s treatment: dialysis, substance abuse, mental health, adult day care, or “other” with a description. Some regional versions of the form also include a diagnosis code field where the treating provider enters the relevant code and description.7Modivcare. Modivcare Standing Order Form
Ordering Party and Physician Signature
The person at the facility completing the form enters their name, title, phone number, and fax number in the ordering party section. Below that, the attending physician or an authorized clinical representative must sign and date the form. A valid National Provider Identifier for the physician may also be required depending on the regional form version. Missing or illegible physician signatures are the single most common reason submissions stall; without a signature, the standing order will not be created.
Choosing the Right Level of Service
The form asks you to select the type of vehicle the patient needs. Getting this wrong can mean the vehicle that shows up cannot safely transport the patient.
- Ambulatory (curb-to-curb): the patient can walk and transfer into a standard vehicle. The driver meets the patient at the curb and helps with seatbelts and mobility aids like canes or folding walkers.
- Wheelchair (door-to-door): the patient uses a wheelchair. The driver assists the patient into and out of the building and secures the wheelchair in the vehicle. A medical necessity form must be on file.
- Stretcher (hand-to-hand): the patient must remain lying down during transport. The vehicle is staffed by a driver and an attendant who assist the patient from the bed onto the stretcher. A medical necessity form is required.
- BLS or ALS: basic or advanced life support transport, for patients with acute conditions who need monitoring during the ride. If you select stretcher, BLS, or ALS, the form asks you to describe the precautions needed.
- Gas reimbursement: for patients whose health plan allows mileage reimbursement when a family member or friend drives them. A separate mileage reimbursement form applies.
Wheelchair and stretcher requests trigger an additional step: you may need to submit a Medical Necessity Form, also called a Transportation Justification Request, along with the standing order.8Modivcare. Level of Service and Escort Expectation In some states, including California, a Physician Certification Statement must be on file before the standing order will be created; without it, trips have to be scheduled individually through the reservation line.9Modivcare. CA Standing Order Form
How to Submit
You have two submission paths, and the portal is faster.
Online portal. Log in to the Facility Services web portal at facility.modivcare.com using the credentials your facility received when it enrolled. Select New Standing Order, complete the required fields (marked with an asterisk), enter your digital signature, and click Create Request.3Modivcare. Facility Services Web Portal User’s Guide If the level of service is anything other than ambulatory, the portal may automatically display a Medical Necessity Form for you to complete before it accepts the submission.
Fax. Print and complete your state’s paper form, then fax it to the number printed on that version. Fax numbers vary by state. Florida uses 1-866-779-5242,5Modivcare. Florida Generic Transportation Guidelines Delaware uses 877-813-5599,10Modivcare. Delaware Facility Resources and Maine uses 877-637-9091.11Modivcare. Modivcare Standing Order Form Your state’s facility resource page at modivcare.com/facilities lists the correct number. After faxing, call the facility line to confirm the document reached intake.
Submit at least five business days before the first scheduled ride. Maine’s form states it must be submitted no later than two business days before the start date,11Modivcare. Modivcare Standing Order Form but the portal enforces the five-business-day window,3Modivcare. Facility Services Web Portal User’s Guide and the longer lead time is the safer default. Modivcare staff review each submission for completeness and verify the medical facility is an active participant in the network before activating the order.
Recertification and Attendance Verification
A standing order is valid for three months. At the end of that period, Modivcare’s team contacts the facility to confirm the order is still needed.12Modivcare. Tennessee Facility Resources If nothing has changed — same patient, same schedule, same facility — the facility confirms and trips continue without a new form. If the schedule, location, or level of service has changed, submit a new standing order reflecting the updates.
By signing the form, the ordering party also agrees to provide attendance verification reports when Modivcare requests them.13Modivcare. National Standing Order Form Attendance verification is how Modivcare confirms the patient actually attended the appointment the ride was booked for. Facilities that ignore these requests risk having the standing order suspended, because unverified trips draw attention in Medicaid fraud-and-abuse audits.
Escorts and Additional Riders
A medically necessary escort or attendant can ride along with the patient at no extra cost, but the escort must be identified when the ride is arranged. Children, legal dependents, and other people in the patient’s care may also ride along in some states, as long as the need is noted upfront. Driver assistance depends on the level of service: ambulatory drivers meet the patient at the curb and help with seatbelts and mobility aids but cannot lift or physically support patients; wheelchair drivers provide door-to-door service and will assist the patient into and out of the building but cannot enter the patient’s home; stretcher vehicles carry an attendant who remains in the patient compartment while the vehicle is moving.8Modivcare. Level of Service and Escort Expectation
If a Friend or Family Member Drives Instead
Some health plans allow the patient to receive mileage reimbursement when a friend or family member drives them, in place of a Modivcare vehicle. That is a separate process from a standing order and uses its own form. The driver has to record the trip number and trip date on the reimbursement form as soon as the trip number is issued, or the payment can be denied. Each form covers only one driver, so if two people take turns driving the patient, each needs a separate form. The treating physician also signs to confirm the patient attended the appointment.14Modivcare. Mileage Reimbursement The reimbursement rate depends on the health plan and state Medicaid program.
If a Standing Order Is Denied or a Ride Goes Wrong
You can file a complaint by phone, through Modivcare’s online WeCare form, or by faxing a completed complaint form to the number listed on your state’s version. Georgia’s, for example, goes to 877-601-0620.15Modivcare. Complaint Form Complaints generally must be filed within 60 days of the incident.
If you disagree with the outcome, you can escalate to a second-level complaint within 30 days of the initial decision, and Modivcare has 10 days to resolve it. For urgent safety issues such as accidents, injuries, threats, or misconduct, a national Executive Escalation line is available at 800-597-2069. Contacting your state’s Medicaid office directly is also an option if Modivcare does not resolve the issue through its internal process.