Lift Eligibility PDF Details

The Lift Eligibility Form is a form that is used to determine the eligibility of an individual for lift services. The form is used by both thelifting individual and the lifting company to ensure that all requirements are met before any services are provided. By using the Lift Eligibility Form, both the lifting individual and company can be assured that they are in compliance with any applicable laws or regulations. Additionally, using the Lift Eligibility Form can help to prevent any misunderstandings or disputes from occurring. For more information on how to complete and submit the Lift Eligibility Form, please visit our website.

This table has got information about lift eligibility. Prior to fill out the form, it is definitely worth checking more about it.

QuestionAnswer
Form NameLift Eligibility
Form Length9 pages
Fillable?Yes
Fillable fields88
Avg. time to fill out19 min 55 sec
Other namestrimet lift applications, trimet lift rider s guide, eligibility lift, trymetlift

Form Preview Example

LIFT ELIGIBILITY PROCESS INSTRUCTIONS

Step 1: WHO MAY BE ELIGIBLE FOR LIFT SERVICE?

The TriMet LIFT service provides paratransit transportation to persons who are certified as eligible under the standards of the Americans with Disabilities Act (ADA). The ADA is a federal law that requires paratransit transportation be provided for persons when their disability in combination with their functional abilities prevents them from using regular public transportation.

Please read the enclosed brochure entitled LIFT Eligibility and the Americans with Disabilities Act and the information about TriMet’s services including bus and MAX before completing your application.

Requirements for LIFT Eligibility

The ADA includes two requirements for LIFT eligibility:

1.you must have a disabling health condition, and

2.your disabling health condition must prevent you from using regular bus and/or MAX services on your own, either some or all of the time.

The basis for the eligibility decision is your ability to use TriMet’s regular bus and/or MAX services and the most limiting conditions presented by your disability and the environment.

LIFT eligibility is not based on:

age alone

a disability or medical diagnosis by itself

a lack of TriMet bus or MAX service in an area

an inability to drive

personal finances

LIFT eligibility may be granted upon the following basis:

Unconditional (the person may use LIFT service for all trips)

Conditional (the person may use LIFT service under some conditions for some trips)

Temporary (the person may have conditional/unconditional eligibility for a defined period of time because limitations are expected to change)

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Step 2: HOW IS YOUR ELIGIBILITY DETERMINED?

The TriMet LIFT eligibility determination process includes:

1.Submission of a completed application and signed Medical Release Form,

2.Professional verification of disability and abilities,

3.An in-person interview with a TriMet LIFT Eligibility Coordinator, and

4.A functional and/or cognitive assessment as needed.

Interview

At the interview, the Eligibility Coordinator will review the application with you and discuss your travel abilities and limitations in more detail. This information will help the Eligibility Coordinator to identify the best mobility option based on your functional abilities.

The interview will take up to 30 minutes. At the end of the interview, the Eligibility Coordinator will determine if a functional ability assessment is required.

If you will require a non-English language interpreter at the interview, please indicate your language on the application form. A third-party interpreter will be provided at no cost to you.

Functional Ability Assessment

You may be asked to complete an assessment of your functional abilities immediately following the interview. The assessment is designed to help determine whether you have the ability to use fixed-route services and if so, under what circumstances.

The functional assessment will be conducted by an independent Mobility Assessor and consist of demonstrating your abilities on a simulated course that includes slopes, inclines, negotiating a curb and curb cut and crossing the street. Skills evaluated also include balance, strength, coordination and range of motion.

The assessment may also include a walk outside in the neighborhood and/or a short trip on bus and/or MAX. Please dress appropriately for the weather.

The Functional Assessment of Cognitive Transit Skills (FACTS) may be administered to applicants with cognitive disabilities. This assessment tool uses a set of photos of a simulated bus trip to assess a person’s transit skills including bus travel, community safety and general orientation.

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Personal Care Assistance

If you require personal assistance in any daily life functions including using the bathroom, you will need to have someone accompany you to the evaluation to provide this assistance.

TriMet staff is not trained and is unable to assist you with personal care issues.

Depending on the time of day for your appointment, you may also want to bring a light snack with you and any required medications.

Mobility Equipment

Please bring the mobility equipment you will use on LIFT and/or in your daily mobility (i.e. mobility device, walker, cane, etc.).

Transportation to the Evaluation

LIFT eligibility evaluations take place at the TriMet Transit Mobility Center (TMC) at 515 NW Davis Street, Portland, OR 97209. The TMC is located on the MAX Green and Yellow Lines between NW 5th and 6th Avenues and NW Davis and Everett Streets. LIFT will provide transportation for your trips to and from the evaluation at no charge to you if necessary. This location is also served by several bus routes and there is parking available at your cost.

STEP 3: HOW WILL I KNOW IF I AM ELIGIBLE?

Notice of Eligibility Determination

You will be notified of the eligibility determination by letter within 21 days after completion of the evaluation process. If you are eligible, you will also receive a LIFT Rider’s Guide with information about how to use the service.

Appeals Process

If you have any questions about your eligibility determination, you may contact your LIFT Eligibility Coordinator as indicated in the letter to review his or her decision.

Applicants who are determined not eligible or who do not agree with the conditions established for their use of the LIFT service may request an appeal which must be filed within 65 days from the date of the initial eligibility determination. Information on how to request an appeal will be included with the eligibility determination letter.

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STEP 4: INSTRUCTIONS FOR COMPLETING THE APPLICATION

1.Answer all questions completely and to the best of your ability.

2.Be sure to sign the application in Part F on Page 3. Incomplete and/or unsigned applications may be returned to you.

3.Complete and sign the attached Medical Release Form (the last page of the application). Incomplete or unsigned Medical Release Forms may be returned to you.

PLEASE NOTE: This is not a request for medical records or a requirement for you to get a signature from your health professional. Once your application has been received, TriMet will contact your health professional to confirm your disability.

Examples of health professionals include:

Certified Orientation & Mobility Specialist

Chiropractor

DSHS/DDD Case/Resource Manager

HCS/AAA Case Manager

MSW employed by a medical facility

Occupational/Physical Therapist

Physician/ Physician Assistant

Psychiatrist/Psychologist

Recreation Therapist

Registered Nurse/Nurse Practitioner

Special Education Teacher

Vocational Rehabilitation Counselor

4.Return the completed application in the enclosed self-addressed envelope or mail to: TriMet LIFT Transit Mobility Center

515 NW Davis Street Portland, OR 97209

Or fax the application to LIFT Eligibility 503-962-8229.

5.After your application has been reviewed, you will be contacted by phone by LIFT staff to schedule your appointment for the in-person evaluation.

Questions? Please call the LIFT office at 503-962-8200 or TTY at 503-962-8058, 8 a.m. – 5 p.m., Monday through Friday. Materials are available in large print and other alternative formats. Assistance for non-English applicants is also available.

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FOR TRIMET USE ONLY

APPLICATION FOR TRIMET LIFT PARATRANSIT SERVICE

Please read carefully. All questions must be answered. Incomplete or unsigned applications may be returned.

Part A. Personal Information

Name

 

Last

 

First

Middle

Home Address

 

 

Unit/Apt. No

City

 

 

State

Zip

 

 

 

 

 

 

 

 

 

Mailing Address (if different)

 

 

Unit/Apt. No

 

 

 

 

 

City

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

Phone Number(s)

Email Address_________________________________________________________

Preferred Method of Contact: Phone Email TTY VRS Web/Video Chat

Date of Birth ______________________Language of Choice

Are you currently a LIFT Customer? Yes No

Are you a TriMet Employee, Dependent of a TriMet Employee, TriMet Retiree, or TriMet Contractor? Yes No

Part B. Emergency Contact Person

Name ____________________________ Relationship to Applicant ______________

Phone Number(s) _____________________________________________________

Email Address________________________________________________________

Additional Emergency Contact: ___________________________________________

1

Part C. Disability and/or Health Condition Limiting Your Mobility

1.What is the disability or health condition(s) that limits your mobility and prevents you from using TriMet regular bus and/or MAX service?

 

 

 

 

 

 

_______________

2.

Do the effects or symptoms of your condition vary daily?

Yes

No

 

If yes, please explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Is your condition: Permanent Temporary

 

 

 

 

 

 

If temporary, what is the estimated recovery period?

 

 

Month(s)

Year(s)

 

 

 

 

 

 

 

 

 

Part D. Mobility Equipment

1.Indicate which mobility equipment you presently use and would be using when traveling on TriMet LIFT.

None

Manual Wheelchair

Service Animal

Cane

Power Wheelchair

Portable Oxygen

Walker

Power Scooter

Respirator

Crutches

Extended Footrests

Chest Restraint

White Cane

Lift Mechanism (to board the bus)

Prosthetic device

Other - please describe:

 

2. If you use a Manual or Power wheelchair or scooter, do you want to transfer to a seat from your device when riding on TriMet LIFT?

Yes No Sometimes, please explain:

Part E. Optional Information:

The following questions are optional and will have no bearing on your eligibility for TriMet LIFT service.

1.What is your ethnicity?

African American

Asian/Pacific Islander

Caucasian

Hispanic/Latino

Native American

Other____________

2.What is your gender? Female Male Non-binary Other___________

3.Are you a US Veteran? Yes No

4.How did you find out about TriMet LIFT service?

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Part F. Please read the following and sign the application

For the applicant: Applications must be signed. Unsigned applications may be returned.

I understand that the purpose of this application is to determine whether I am eligible to use TriMet LIFT paratransit services. I certify that the information in this application is true and correct. I understand that providing false information may result in denial of service as well as penalty under the law. I understand that information I provide will be disclosed only as needed to evaluate eligibility for LIFT paratransit, and to provide LIFT services if I am determined to be eligible, unless I give other specific authorization.

I understand that it may be necessary for me to participate in an in-person evaluation at TriMet’s expense, to determine my eligibility for LIFT services. I understand that TriMet may review my current ADA LIFT eligibility status at any time whatsoever where circumstances may warrant that I am no longer eligible to receive ADA LIFT transportation service. I give my consent to TriMet or a TriMet Designated Administrative Agency* to take and retain a copy of my photo for purposes of identification for the LIFT and Honored Citizen program. If I am determined eligible for LIFT paratransit service, I will be eligible for the Honored Citizen Program in the event I decide to use the regular bus, MAX or WES trains. I will be sent a TriMet hop card with instructions for use on all TriMet vehicles.

*For the purpose of simplifying the administration of the LIFT program, social service agencies and other organizations that are interested in assisting with completing LIFT applications for their clients may be selected, at TriMet’s discretion, to operate as a Designated Administrative Agency.

If a legal representative signs this application:

I acknowledge that I may be present with the applicant during the in-person evaluation, or I may designate someone to be present on my behalf.

_____________________________________________________________________

Applicant signature, or signature of legal representative

Date

If someone other than the applicant assisted in completing this application, in part or in whole, that person must complete and sign the following:

Name:____________________________Relationship to applicant: ______________

Organization or Agency affiliation: _________________________________________

Address:_____________________________________________________________

Phone: _________________ Fax: ______________ Email: _____________________

I have knowledge of the applicant’s disability or health condition and am aware of how the applicant’s disability or health condition prevents their use of TriMet regular bus and/or MAX: Yes No

____________________________________________________________________

Representative’s signature

Date

 

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Part G. Instructions regarding signatures and submitting application

Before returning the application, please make sure that:

1.You answer all questions in Parts A through F.

2.You sign Part F on Page 3.

NOTE: If another person (not the applicant) completed the application, please have that person complete the information in Part F and sign the application.

3.You complete and sign the attached Medical Release – Authorization For Use and Disclosure Of Protected Health Information on Page 6. The Medical Release form is available in large print upon request .

It may be necessary for TriMet to contact a health professional who is familiar with your disability or health condition. TriMet will not release any medical information obtained with the release(s) you provide to any other party.

Please use the enclosed self-addressed envelope or mail your application to:

TriMet Transit Mobility Center

515 NW Davis Street

Portland, OR 97209

You may instead fax the application to 503-962-8229.

If you have any questions or need assistance in completing the application, including an alternative format, please call the Transit Mobility Center at 503-962-8200, Option #4, TTY 7-1-1

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MEDICAL RELEASE

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

All sections must be completed.

I, _______________________________________ authorize:

(Applicant or Patient Name)

Name of professional ________________________________________________________

Address ___________________________________________________________________

Phone ________________________________ FAX _______________________________

to disclose Protected Health Information (PHI) to the TriMet LIFT (paratransit) Program, 515 NW Davis Street, Portland, OR 97209, for the purpose of assessing whether I am eligible under the Americans with Disabilities Act for TriMet’s LIFT transportation service. Only those persons with disabilities whose disabilities prevent their use of regular TriMet buses and/or MAX service are eligible to use LIFT service.

My PHI may include medical records, diagnostic reports, physical therapy records, and any personal and medical information pertinent to my application for LIFT eligibility. If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my initials in the space next to the type of information:

___________ Chemical dependency

___________ Sexually transmitted diseases HIV/AIDS

___________ Genetic information

___________ Mental health information (excludes psychotherapy notes)

___________ Reproductive health (including abortion)

I may cancel this authorization at any time by sending a written request to the TriMet LIFT Program,

515 NW Davis Street, Portland, OR 97209. My cancellation of this authorization will not affect any uses or disclosures made before my request is received. If I do not revoke this authorization, it will automatically expire in 90 days.

I understand that I am not legally obligated to sign this authorization and that TriMet will not refuse to accept my application for LIFT eligibility based on my refusal to sign this authorization. I also understand that if TriMet is unable to obtain information necessary to determine my disability or health condition and how the disability or health condition limits or prevents my use of regular bus and/or MAX services, my application for LIFT eligibility may not be processed or may be denied.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be legally protected. However, I also understand that federal or state lay may restrict redisclosure of HIV/AIDS information, mental health information, genetic information and drug/alcohol information.

I understand that by signing this statement I am authorizing TriMet to provide a copy of this statement to the above listed professional for the purposes of compliance with the Health Insurance Portability and Accountability Act (HIPAA).

_________________________________________________

__________________________

Signature of applicant or legal representative

Date

Applicant’s Date of Birth _____________________________

 

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