HRT Application Form – Fill Out and Use This PDF

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

Identify the medical professional most knowledgeable about your functional abilities, for example your personal physician or psychiatrist.

For the medical professional, fill in Name of Medical Professional, Phone, Fax, Address, City, State, Zip and What is this person's professional field or expertise? Identify 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., with Name of Professional and the same fields and What is this person's professional field or expertise? Do not identify a friend or family member.

By your signature, the licensed or certified professionals you list are authorized to release to Hampton Roads Transit any necessary information about your disability (or that of your child or the person for whom you are legal guardian, as appropriate), including medical information and records, in order to verify eligibility for ADA complementary paratransit services. Sign here to authorize this release.

This authorization will expire, without your 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.

You may revoke this authorization in writing at any time except to the extent that action has been taken based on it.

Enter Name: Last, Initial, First and Suffix.

Enter the Home Address with Apt. #, then City, State and Zip. If different, enter a Mailing Address with Apt.#, City, State and Zip.

Enter Daytime Phone, TDD/TTY, Evening Phone, Mobile Phone and E-mail.

Enter Birth Date and mark Gender: Female or Male.

Mark Yes or No: Do you need this application and future written information provided to you in an accessible format? If yes, check which format(s) you can use, and circle the one you prefer: Audio Tape, Braille, Diskette, CD-Rom, Large Print, E-mail or Other (specify).

Mark Yes or No: Do you need a sign interpreter or other assistance for your eligibility interview? If yes, explain.

Mark Yes or No: Are you currently eligible for Medicaid transportation?

If a person other than applicant helped to fill out this form, identify that person: Name, Phone, Address, City, Zip and Relationship to applicant.

Identify a person to notify in case of an emergency, if needed: Name, Day Phone, Relationship and Eve. Phone.

Answer the following questions in detail, and use extra paper if needed: 1. What is/are your disability (ies)?

2. How does your disability (ies) prevent you from independently using the public fixed route transit system?

3. Are the condition(s) you described permanent or temporary? Check one. If temporary, write what the condition(s) are expected to continue until.

4. How do you currently travel within the Hampton Roads area? Check all that apply and identify how often you use each in an average week, in round trips per week: Someone drives me, Drive myself, HRT bus, School bus, Handi-Ride, Taxi, Social service agency vehicle, or Other.

5. Does your disability change from day to day in a way that affects your ability to use public fixed route transit? Mark Yes, good on some days, bad on others, No, same all the time, or Don't know. If you checked “yes” or “don't know,” please explain.

6. Do you know the location of the bus stop nearest your residence? Mark No (Go to Question 7), or Yes and enter the Location and how far the stop is from your residence: On your block, 1 block, 2 blocks, 3 blocks or 4 blocks. Then, going to, from and/or at the stop you listed, mark No or Yes for any specific conditions or barriers that prevent you from using the bus; Yes, if yes, please explain.

Do you use any of the following mobility aids or specialized equipment? Check all that apply and circle the one you use most frequently: Cane, Crutches, Wheelchair/Scooter, Walker, Communication Board, White Cane, Service Animal, None or Other 8.

Do you need the assistance of a personal care attendant (someone provided by you) to accompany you when you travel outside your home? Mark Yes, always, No or Sometimes (please explain).

You certify that the information in this application is true and correct to the best of your knowledge.

Any falsification of the information you provide in this application may result in denial of service and possible criminal sanctions.

You must notify the Hampton Roads Transit paratransit office of any changes in disability or travel that affect your ability to use public transit.

Sign on the Applicant (or parent/legal guardian) Signature line, then enter the Date and Print Applicant Name. In compliance with the Americans with Disabilities Act of 1990 (ADA), Hampton Roads Transit (HRT) 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.

Mail your completed application form to Hampton Roads Transit, Attention: Handi-Ride Certification, 3400 Victoria Boulevard, Hampton, VA 23661.