IEHP NEMT Transportation Form: Physician Statement, Submission, and Denials

To arrange non-emergency medical transportation through IEHP, your doctor completes two documents — a Physician Certification Statement (PCS) and a Transportation Request Form — and submits them together to IEHP through the provider portal, by fax, or by secure email at least five calendar days before your appointment. The IEHP transportation form process starts in your provider’s office, but you need to give them the right information and know what each form should contain so nothing stalls the request.

Who the Forms Are For

NEMT is approved when a health condition prevents you from traveling by bus, car, taxi, or any other form of public or private transportation.¹ If you simply lack a ride or live far from a bus stop, that falls under IEHP’s separate Non-Medical Transportation (NMT) benefit, which provides rideshares and bus passes and uses a different request path. NEMT covers ambulance, litter van or gurney, and wheelchair van trips to medical, mental health, substance use, and dental appointments that are prior-authorized IEHP and Medi-Cal covered services.² It does not cover trips to the pharmacy; IEHP has a separate no-cost prescription delivery program for that.

What to Give Your Doctor

Your provider prepares both forms, but have this information ready so the appointment doesn’t get stuck on missing details:

Your IEHP member ID from the front of your insurance card
Your date of birth exactly as IEHP has it on file
The facility name, full address, date, and time of your medical visit
The type of transport you believe you need (ambulance, litter van or gurney, wheelchair van, or air). Your doctor makes the final call based on your condition.
Any pickup instructions a driver would need, such as an apartment number or gate code

The same forms and procedures apply whether the appointment is inside or outside Riverside and San Bernardino counties.¹

What Goes on the Physician Certification Statement

The PCS establishes medical necessity. The Department of Health Care Services requires it for all Medi-Cal NEMT services, and IEHP uses the DHCS-approved version.³ Your provider fills it out, but check these fields before it goes anywhere.

The member section lists your name, date of birth, IEHP member ID, and the transportation start and end dates. The end date automatically sits 12 months from the start, and the certification covers all NEMT requests during that period. There is no exception, even for permanent conditions. Your provider will need to submit a new PCS each year.

The provider then selects a transportation mode (ambulance, litter van or gurney, wheelchair van, or air) and marks every functional limitation that applies:

Paraplegic, hemiplegic, or non-ambulatory
High fall risk (requires an explanation)
Poor exercise tolerance
Requires oxygen
Hemodialysis patient
Requires extensive medical support such as a ventilator or IV
Dementia or behavioral issues
Blind
Special positioning or handling required
Requires a mobility device
Other, with an ICD-10 diagnosis code

The provider signs and prints their name and enters their National Provider Identifier (NPI).⁴ A missing NPI or an unsigned form will hold up the whole request, so confirm both before the paperwork leaves the office.

What Goes on the Transportation Request Form

The Transportation Request Form handles the logistics of the actual trip. If your provider submits through the portal, several fields auto-populate from the PCS and your member record. The form captures:

The requesting provider
Member health information relevant to the trip
The pickup address with any special driver instructions
The destination address and department within the medical facility
Transportation mode (ambulatory, wheelchair, or gurney), with additional detail fields for wheelchair and gurney selections
Request type: hospital discharge, skilled nursing or long-term care facility, or standard outpatient appointment

All fields are required.⁵ Two common reasons a form gets kicked back: incomplete addresses, and a mismatch between the transportation mode on the PCS and the mode on the request form.

How the Forms Get Submitted

Providers have three ways to send both forms to IEHP:

Provider portal. The preferred route. The portal walks providers through both forms in sequence, auto-populates member data, and produces a confirmation that can be downloaded for your file. If no current PCS is on record, the portal prompts the provider to complete one first.⁵
Fax. Send both completed forms to (909) 912-1049. The line runs Monday through Friday, 7 a.m. to 7 p.m., and Saturday and Sunday, 8 a.m. to 5 p.m.⁶
Secure email. Providers without a portal account can email the PCS to transportationservices@iehp.org.³

If you need help at any point, call IEHP Member Services at 1-800-440-IEHP (4347). TTY users should call 1-800-718-4347.⁷

How Far in Advance to Submit

IEHP requires at least five calendar days’ notice for a routine medical appointment.⁸ Requests made with less notice are subject to vehicle availability and are not guaranteed. Hospital discharges and dialysis appointments are exempt from the five-day requirement.⁵ For other urgent appointments, IEHP will try to arrange a ride sooner depending on availability.¹ Call Member Services directly and explain the situation.

As of May 16, 2026, IEHP arranges all NEMT trips directly, so you do not need to contact a separate transportation company after your forms are approved. Call the Car continues to handle NMT (non-medical) trips only.¹ Once your request is approved, IEHP coordinates the vehicle and tells you the pickup details. Have your IEHP card with you on the day of the ride.

Companions and Service Animals

One extra passenger is allowed on your NEMT trip if you need assistance, such as a family member, caregiver, or aide.¹ Mention the companion when scheduling so the vehicle has space. Service animals are also allowed; IEHP does not list a special documentation requirement, but tell the transportation team in advance so the driver is prepared.

If Your Request Is Denied

IEHP notifies both you and the requesting provider when a request is approved or denied. The most common reason for denial is a PCS that doesn’t clearly establish why you can’t travel by ordinary means. If your doctor checked only “other” on the functional limitations list without a supporting ICD-10 code, or left the transportation mode blank, the form may come back. Ask your provider to be specific about your limitations and to complete every required field before resubmitting.

To file a formal appeal, contact IEHP within the timeframe listed on your denial letter. IEHP acknowledges receipt of an appeal within five days, resolves standard appeals within 30 calendar days, and resolves urgent appeals within 72 hours.⁹

For a complaint about the service itself — a late driver, a missed ride, or a problem with the vehicle — call Member Services at 1-800-440-IEHP (4347) for a same-day issue, or file a grievance by fax at (909) 890-5748, by mail to IEHP Grievance Department, P.O. Box 1800, Rancho Cucamonga, CA 91729-1800, or in person at 10801 6th St., Rancho Cucamonga, CA 91730-5987.¹⁰

1
Inland Empire Health Plan. Transportation
2
Inland Empire Health Plan. Medi-Cal Benefits and Services
3
Inland Empire Health Plan. Non-Emergency Medical Transportation Physician Certification Statement
4
Inland Empire Health Plan. Non-Emergency Medical Transportation Physician Certification Statement
5
Inland Empire Health Plan. Make Non-Emergency Medical Transportation (NEMT) Requests on Provider Portal
6
Inland Empire Health Plan. IEHP Transportation Services – Appointments
7
Inland Empire Health Plan. Transportation Flyer
8
Inland Empire Health Plan. Update – NEMT Transportation Requests Require Five Calendar-Day Notice
9
Inland Empire Health Plan. Member Appeals Resolution Process
10
Inland Empire Health Plan. Member Grievance Resolution Process