Application for MetroAccess Door to Door Paratrans 2017-2026

Application for MetroAccess Door-to-door Paratransit Service For People with Disabilities Transit Accessibility Center 600 5th Street NW Washington DC 20001 202 962-2700 select option 5 TTY 202 962-2033 DO NOT MAIL OR FAX APPLICATION All Assessments are by Appointment Only Thank you for your interest in Metro services for people with disabilities. The following services are available based on Metro s determination of your eligibility A Reduced Fare Program for People with Disabilities Eligible people with disabilities travel on accessible Metrobus and Metrorail for half the regular rush hour fare at all times. This program is available for people with disabilities who need to use accessible bus and rail public transportation* For more information on the Reduced Fare program or to obtain an application please visit our website at http //www.wmata*com/accessibility/metroaccess_eligibility.cfm under the section titled How do I get a Metro Disability ID Card or call 202 962-2700 and select option 1 from the phone menu. B Free Metro System Orientations Travel Training Metro provides free individualized training to help people with disabilities learn how to use the Metro bus and rail systems for safe and independent travel around the region* For more information contact the Office of ADA Programs at 202-962-1558 are unable to use regular accessible bus and rail public transportation* The Americans with Disabilities Act ADA outlines specific criteria to determine eligibility for paratransit service and an application an in-person assessment is required* MetroAccess operates throughout the metropolitan area where there is regular bus and/or rail service. Service is provided in Washington DC Montgomery County and Prince George s County in Maryland Arlington County Fairfax County City of Alexandria City of Fairfax and City of Falls Church in Virginia* To apply for this service you and your healthcare provider must complete this application* Please read and follow the instructions on page 2. Page 1 of 8 Instructions Step 1 Read the entire application and complete Part A. Step 2 Read Accessible Transportation Options for People with Disabilities and Senior Citizens in the Washington DC Metropolitan Area included with this application packet or also available at http //www.wmata*com/accessibility/doc/Accessible_Transportation_Options.pdf Step 3 Take the entire application to a healthcare provider holding active licensure or credentials in the area of your disability to complete Part B. One of the following health care providers must certify the application Physician Physician s Assistant Certified Nurse Practitioner Optometrist visual disabilities only Podiatrist disabilities of the foot and ankle only or Licensed Clinical Psychologist Psychiatric disabilities only . It is your responsibility to ensure the original application is received by the Metro Transit Accessibility Center on the day of your appointment. . Step 4 Upon completion of the application contact the Transit Accessibility Center at 202962-2700 and select option 5 TTY 202-962-2033 to conduct a pre-assessment interview. At that time a determination will be made as to the type of appointment and/or assessment that will be required and an appointment will be made for you. Please have your application at hand when you call* Also ensure you contact the office within 60 days of the date of the healthcare provider s signature. Applications more than 60 days old will not be accepted* You will be instructed to bring your completed original application with you to the appointment. Do not mail or fax the application* NOTE We reauire 24 hours notice if you need to cancel your appointment except in case of and emergency. If you miss or cancel 2 appointments you will have to reapply. Copies faxes and scans will not be accepted* Applications with missing information will not be accepted and will be returned to the applicant without processing* Applications that are mailed will be returned to the applicant with instructions to contact the Transit Accessibility Center Step 5 Metro will determine your eligibility based on how your disability impacts your use of accessible bus and rail public transportation* The assessment will take place at the Metro Transit Accessibility Center. If you use a mobility aid you must bring it with you to the assessment. If transportation is needed advise the Metro Transit Accessibility Center representative at the time of your telephone interview. If you have questions or need additional information please contact the Metro Transit Accessibility Center at 202-962-2700 and select option 5 TTY 202-962-2033 or e-mail eligibility wmata*com* Please do not bring children to the appointment unless the child is the applicant. The office is open Monday Wednesday - Friday from 8 00 AM - 4 00 PM and Tuesday 8 00 AM to 2 30 PM. Hours are subject to change without notice. Phone lines open at 8 30 on all days. Please call in advance. I am a current MetroAccess customer. MetroAccess ID Card ________________________ I am a current Reduced Fare customer. Reduced Fare ID Card ________________________ __________________________________________________________________________________________ Part A APPLICANT INFORMATION AND RELEASE Copies faxes or scans will not be accepted Last Name______________________________ First Name______________________________ Middle Initial ________ Street Address Apartment City State Zip County or City Gender Male Female Date of Birth ____/______/________ E-mail _________________________________ Primary phone number Secondary phone number In case of an emergency who should be notified Name Relationship Phone Mobility Devices Do you require the use of a mobility device when traveling No Yes Check all that apply Manual Wheelchair Support Cane Portable Oxygen Power Wheelchair or Scooter up to 48 x 30 and no more than 600 pounds when occupied Crutches Walker White Cane for visually impaired Other _____________________________ Do you use a service animal No Yes Sometimes If yes please describe the type of animal and what service s the animal was trained to perform Frequent Trips Please list the two trips that you make most frequently. From Place and Address To Place and Address What barrier s prevent you from using public transportation You will be asked to provide details of the barrier at the time of your assessment appointment Lack of accessible path to bus stop Lack of curb cut Lack of sidewalk Lack of a bus shelter Lack of a bench Lack of audible pedestrian signal Lack of Braille or tactile marking to identify bus stop Cars parked in bus stop Other ____________________________________________________________________ None. I am able to independently use public transportation* To the best of my knowledge I certify that the information provided in this application is correct. Original Signature of Applicant __________________________________________ Date _________________________ Under 18 Signature of Parent or Guardian I certify that I have the legal authority to complete this application or that I have the applicant s permission* A copy of the power of attorney or other authorizing document is attached* Printed Name Signature Address Part B HEALTH CARE PROVIDER CERTIFICATION or the applicant s primary care provider as outlined on page 2 must complete Part B. Your patient has requested eligibility for MetroAccess services. MetroAccess is a door to door shared ride paratransit service for people whose disability ies prevent them from riding the fixed route accessible system all or part of the time. As the applicant s healthcare provider you are uniquely qualified to clarify his or her functional abilities and limitations to ride the Metro s that you complete and certify the following sections. Please detail how the applicant s disability ies impact their ability to board navigate and travel on the fixed route system* Customer s HIPAA Authorization I _________________________________authorize the healthcare provider completing this application to release to the Washington Metropolitan Area Transit Authority Metro any protected health information about my disability in order to verify my eligibility for Metro Services for People with Disabilities. I also authorize the release of further information should it be needed for this application for a period of 60 days from the date of my signature on part A of this application* functional assessment to determine eligibility for Metro services for people with disabilities. 1. Name of Health Care Provider Please print ____________________________________________________ 6. Specialization ___________________________________________________________________________________________ 7. Diagnosis es including ICD and/or DSM Code s ______________________________________ 8. HYPERTENSION Eligibility for service is determined by a functional assessment which is conducted by a certified/licensed therapist with the Transit Accessibility Center. Applicants may be required to walk/travel up to 1/4 mile. In order to ensure the safety of the applicant a blood pressure B/P reading is taken prior to starting the assessment. If the applicant s resting B/P is 160/100 or higher the assessment will be suspended pending certification by the health care provider that the applicant can complete the assessment. If you are currently treating the applicant for hypertension and certify that he/she is cleared to complete the functional assessment we may proceed without referring the applicant back to you for evaluation and certification* 9. Are you currently treating this applicant for Hypertension No Yes 10. Applicant can complete the assessment as described above if B/P does not go above a reading of ______________________ 11. Does the applicant require a Personal Care Attendant PCA when traveling on public No Yes Sometimes 13. Check all that apply Manual Wheelchair Support Cane Portable Oxygen 14. What is the expected duration of the disability Short-Term Conditions that last at least 90 days but are likely to improve within one year. Long-Term Conditions with absolutely little expectation of improvement 15. Does this applicant s disability ies prevent him/her from independently using the accessible Metrobus and Metrorail system If yes or sometimes when would this applicant s disability ies prevent him/her from riding the 16. In your medical opinion HOW does the disability or health condition impact the applicant s ability to travel independently from one location to another on the accessible Metrobus and Metrorail system 17. If this applicant is currently on medication s will the side effects of this reduce or hinder his/her ability to independently ride the accessible Metrobus and Metrorail system No Yes N/A If you selected yes for this question please explain how the side effects would hinder this ENVIRONMENTAL ISSUES THAT AFFECT THE APPLICANT Based on the applicant s disability ies please tell us if following environmental factors affect his/her ability to ride Metro s accessible bus and rail system* 18. Would extreme heat/humidity affect this applicant s ability to ride the accessible Metrobus or Metrorail Sometimes Metrorail 20. Would ice and/or snow affect this applicant s ability to ride accessible Metrobus or Metrorail system 21. Would poor air quality affect this applicant s ability to ride Metrobus or Metrorail 22. What other environmental factors might affect this applicant s ability to ride Metrobus Note Must be original hand signature not signature stamp False certification may be reported to the licensing agency under District of Columbia Code Annotated Section 2-3305.15 Code of Virginia 54. 1-2915 or Maryland Health Occupations Code Annotated 14-404 or appropriate code for state of license. Metro reserves the right to 1 verify the validity of the license of the for Metro services for people with disabilities and 3 retain a copy of this application*