North Dakota Medicaid uses this one-page certificate to record the mode of non-emergency medical transportation (NEMT) that a member's medical provider has found medically appropriate: wheelchair van, stretcher van, non-emergency ambulance or another NEMT service. The provider notes the reason for transport and qualifying conditions, then attests. The NEMT provider keeps a copy and submits it to ND Medicaid on request.
The member's medical provider is named on the form and determines the mode; the individual completing the form prints their name, signs and dates the attestation.
Download the current version from the source each time; forms change without notice.
Medical Certificate of Transportation Services
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Both sides keep it. The medical provider keeps a copy in the patient's medical record and furnishes a copy to the NEMT provider. The NEMT provider is responsible for retaining the form and submitting it to North Dakota Medicaid upon request.
Not for lifting needs alone. The form says non-emergency ambulance cannot be selected solely for lifting needs without an additional medical condition. The provider checks the reasons that apply, such as dementia-related combativeness, oxygen or IV administration by medical personnel, specialized monitoring, medication en route or advanced airway management.
No. The form states it does not guarantee payment. Payment depends on passing claims edits, the member's and provider's continued Medicaid eligibility, and medical necessity for the transport. The certificate documents the appropriate mode; it does not replace those checks.