HRT Application Form – Fill Out and Use This PDF

CERTIFICATIONS AND AUTHORIZATION TO RELEASE RECORDS

By my signature below, the following licensed or certified professionals are hereby authorized to release to Hampton Roads Transit any necessary information about my disability (or that of my child or the person for whom I am legal guardian, as appropriate), including medical information and records, in order to verify eligibility for ADA complementary paratransit services.

The individual(s) listed below cannot be the individual assisting in the completion of this application.

Please identify below the medical professional most knowledgeable about your functional abilities; for example, your personal physician or psychiatrist.

Name of Medical Professional: ___________________________________________________

Phone: _________________________________ Fax: _________________________________

Address: _____________________________________________________________________

City: __________________________________ State: _________ Zip: ___________________

What is this person’s professional field or expertise? __________________________________

Please identify below another professional who understands your functional ability to use fixed route service; for example, a physical therapist, occupational therapist, rehabilitation specialist, clinical social worker, etc. Please do not identify a friend or family member.

Name of Professional: __________________________________________________________

Phone: _________________________________ Fax: _________________________________

Address: _____________________________________________________________________

City: __________________________________ State: _________ Zip: ___________________

What is this person’s professional field or expertise? __________________________________

•I understand that it may be necessary to contact a professional familiar with my functional abilities to use public transit (or those of my child, or ____________, as appropriate) in order to assist in the determination of eligibility.

•I understand that the medical and other information released by this authorization may include information concerning treatment of physical and mental illness, alcohol/drug abuse and/or past medical history.

•I understand that any information contained in or obtained from this application may not be protected by federal confidentiality rules but will be used solely for the purpose of my request for transportation service.

•I understand this authorization will expire, without my express revocation, one year from the date of signing, or if the applicant is a minor, on the date they become an adult according to state law. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on it. I understand that revocation will not apply to information that has already been released as specified by this authorization.

Applicant (or parent/legal guardian) Signature _______________________ Date____________

Print Applicant Name: __________________________________________________________

Hampton Roads Transit Application for ADA Complementary Paratransit Service

Name: Last __________________Initial___________ First___________________Suffix____

Home Address: _______________________________________________Apt. #:___________

City: _____________________________________State: _________ Zip: _________________

Mailing Address (if different): ____________________________________ Apt.#: __________

City: _____________________________________State: _________ Zip: _________________

E-mail: ______________________________________________________________________

Do you need this application and future written information provided to you in an accessible

format? Yes No

If yes, check which format(s) you can use, and circle the one you prefer:

Do you need a sign interpreter or other assistance for your eligibility interview?

Yes No

If yes, explain: ___________________________________________________________

Are you currently eligible for Medicaid transportation? Yes No

If a person other than applicant helped to fill out this form, please identify:

Name: __________________________________________ Phone: _____ - _______ - _______

Address: ______________________________ City: ___________________ Zip: ___________

Relationship to applicant: ________________________________________________________

Please identify a person we can notify in case of an emergency, if needed:

Name: ____________________________________ Day Phone: _____ - _______ - _________

Relationship: __________________________ Eve. Phone: _____ - _______ - _____________

7.Do you use any of the following mobility aids or specialized equipment? Check all that apply and circle the one you use most frequently:

8. Do you need the assistance of a personal care attendant (someone provided by you)

to accompany you when you travel outside your home (e.g., to push your wheelchair, carry oxygen, assist with tasks, etc.)?

•I certify that the information in this application is true and correct to the best of my knowledge.

•I understand that any falsification of the information I provide in this application may result in denial of service and possible criminal sanctions.

•I understand that I must notify the Hampton Roads Transit paratransit office of any changes in disability or travel that affect my ability to use public transit.

Applicant (or parent/legal guardian) Signature_______________________ Date____________

Print Applicant Name: _________________________________________________________

PLEASE NOTE

In compliance with the Americans with Disability Act of 1990 (ADA), Hampton Roads Transit (HRT) here informs you that within twenty-one days of “receiving a complete application, including professional verification if needed,” a decision concerning your eligibility will be made. You will then be notified of the determination by mail. If a decision is not made by the twenty-first day after your interview, you will become “presumptively eligible”. This status grants you the right to use the Handi-Ride service until the actual determination of your paratransit eligibility. You will be notified by telephone that you are “presumptively eligible”. This status remains in effect until you receive written notification of your eligibility determination.

Please review your application. If it is not filled out completely, it will be returned to you for completion. Send completed application to: Hampton Roads Transit, Attention: Handi- Ride Certification, 3400 Victoria Blvd., Hampton, Virginia 23661.