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 Length11 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 45 sec
Other namestrimet lift eligibility, get a lift application, trimet lift application form, forms lift

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 disability, and

2.your disability 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)

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.

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.

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 4. 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

Physical Therapist

Chiropractor

Psychiatrist

DSHS/DDD Case/Resource Manager

Psychologist

HCS/AAA Case Manager

Recreation Therapist

MSW employed by a medical facility

Registered Nurse/Nurse Practitioner

Occupational Therapist

Special Education Teacher

Physician

Vocational Rehabilitation Counselor

Physician Assistant

 

4.Return the completed application and Medical Release Form by mail to:

TriMet Transit Mobility Center

515 NW Davis Street

Portland, OR 97209

Instead of mailing, you may also fax the application to 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.

For TriMet use only

APPLICATION FOR TRIMET LIFT SERVICE

General Information: Please read carefully. All questions must be answered. Incomplete or unsigned applications will be returned.

Part A. Personal Information

Name: ______________________________________________________________________

Last

First

 

 

Middle

Home Address:

 

 

Apt. No.:

 

Name of facility or apartment building:

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

 

ZIP:

 

Mailing address if different :

 

 

Apt. No.:

 

City:

State:

 

ZIP:

 

Phone Number(s) (list below) :

 

 

 

 

 

 

 

 

 

 

 

 

 

Home:

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

What is your language of choice?

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth:

 

 

Female

 

 

Male

 

 

 

 

 

 

 

Part B. Contact Person(s)

Emergency Contact Person:

Relationship to Applicant:

Emergency phone number(s) (list below):

Primary:

Other:

You may list additional emergency contacts on an additional sheet.

Page 1

Part C. Tell us about your disability or disabling health condition.

1.What is the primary disability or health condition that prevents you from being able to use TriMet’s regular bus and or MAX service? Please be specific (for example: stroke, emphysema, schizophrenia, etc.). _______________________________

_________________________________________________________________

_________________________________________________________________

Date of diagnosis or onset: ___________________________________________

2.Do you have other physical or mental health disabilities or conditions that limit your

ability to use TriMet’s bus and/or MAX service?

Yes

No

If yes, please explain: _______________________________________________

_________________________________________________________________

3.Do the effects of your disability or condition vary from day to day? Yes No If yes, please explain: _______________________________________________

_________________________________________________________________

4.Is your disability or condition:

Permanent

Temporary How long: ______ Month(s) ______Year(s)

If you answered temporary, please explain: ______________________________

_________________________________________________________________

Part D. Tell us about your use of TriMet’s regular bus and/or MAX

1. Have you used regular TriMet buses or MAX trains?

Yes

No

2. Are you able to reach the TriMet bus stop nearest your home?

Yes

No

Sometimes

If your answer is no or sometimes, please explain:

________________________________________________________________

3. What best describes your ability to use TriMet’s regular bus and/or MAX service?

I can use the regular bus or MAX for most trips.

I could use the regular bus or MAX but it would be difficult.

I can use bus or MAX but only for specific trips or destinations

I have never tried to use the regular bus or MAX.

I cannot use the regular bus or MAX without a personal care attendant.

I cannot use the regular bus or MAX at all because: _____________________

Page 2

Part E. Mobility equipment, aids or personal assistance required for travel

1.Mark any and all mobility equipment and aids that you expect to use when you travel.

 

None

 

Manual wheelchair

 

Service animal

 

Cane

 

Power wheelchair

 

Portable oxygen

 

Walker

 

Power scooter

 

Respirator

 

Crutches

 

Extended footrests

 

Picture board

 

White cane

 

Chest restraint

 

Alphabet board

 

Prosthetic device

 

Lift mechanism (to board and leave the bus)

 

Other (Please describe):

 

 

 

 

2. If you use a wheelchair or scooter:

a. Would you be able to transfer to a seat?

Yes

No

b.What is the width of your wheelchair or scooter? ___________inches

c.What is the length of your wheelchair or scooter? __________inches

3.TriMet operators are unable to perform the duties of a Personal Care Attendant (PCA). Will you need to travel with a PCA or someone to assist you when use LIFT?

Always

Sometimes

Never

If always or sometimes, how does a PCA or other person assist you?

__________________________________________________________________

3.Some persons cannot be left alone at their residence or other destination; for example, persons with dementia or Alzheimer’s disease. Does someone always need to meet you when you arrive at a destination?

Yes

No

NOTE: If you answered yes, there must be someone to meet you on all trips you take on LIFT. If no one is available at your destination, LIFT would call the contact person listed in Part B.

Page 3

Part F. Please read the following and sign the application.

For the applicant: Applications must be signed. Unsigned applications will 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.

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 or legal representative

Date

If this application was completed by someone other than the applicant:

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

Relationship to applicant: ____________________________________________________

Name: ____________________________________________________________________

Address: __________________________________________________________________

Phone: _______-________-__________ Other: _______-______ -__________

Organization or agency affiliation: _____________________________________________

I have knowledge of the applicant’s disability or health condition.

Yes

No

I am aware of how the applicant’s disability or health condition limits or prevents

use of regular TriMet bus and/or MAX.

Yes

No

______________________________________________________________________________

Representative’s Signature

Date

Page 4

PART G. Instructions regarding signatures and submitting application to LIFT

Before returning the application, please make sure that:

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

2.You sign Part F on Page 4.

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 503-962-8058.

LIFT Application w/Instructions – 4-13-11.docx – www.trimet.org

Page 5

- 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 law 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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