Mbta Transportation Access Pass Form PDF Details

Navigating public transportation can be a significant challenge for individuals with disabilities, underscoring the importance of programs designed to make this process more accessible. Among these, the Massachusetts Bay Transportation Authority (MBTA) offers a ray of hope through its Reduced Fare Program, featuring the Transportation Access Pass (TAP) CharlieCard. This pass is a cornerstone in promoting accessibility, offering reduced fares across the MBTA services for eligible parties. The application process is straightforward but critical, comprising sections that require detailed information from the applicant, emergency contact specifics, and a pivotal component handled by a healthcare professional. First-time applicants and those seeking renewal must navigate through the eligibility criteria with precision, providing accurate proof of their status—whether it is a Medicare Card, verification from the Department of Mental Health, or documentation confirming a disability rating for veterans, among others. For those whose circumstances don't automatically guarantee eligibility, a thorough assessment by a licensed health care professional becomes a crucial part of their application, underscoring the MBTA’s commitment to accommodating a wide spectrum of disabilities. This inclusive approach reflects in the criteria designed to identify various types of disabilities, ensuring those with physical, psychiatric, intellectual, or sensory challenges receive the support they need. The TAP CharlieCard isn't influenced by income but rather focuses on the level of difficulty an applicant may face when using public transport, reaffirming the MBTA's holistic view towards accessibility.

QuestionAnswer
Form NameMbta Transportation Access Pass Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmbta disability, mbta access pass, mbta disability pass phone number, mbta disability pass

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COMMONWEALTH OF MASSACHUSETTS

REDUCED FARE PROGRAM Transportation Access Pass/TAP CharlieCard Application

PART A: To Be Completed By Applicant (Please print)

Applicant Information: First time applicant Renewal

Last Name___________________ First Name _______________ MI____

Address _____________________________________Apt. No.________

City ______________________________ State ________ Zip_________

Phone ____________________________ DOB _____/_____/__________

E-Mail ______________________________________________________

Emergency Contact Information: Name __________________________

Relationship __________________ Phone _________________________

Disability Information Release Authorization:

I authorize the health care professional completing this application to release information about my disability to the Massachusetts Bay Transportation Authority (MBTA).

_______________________________

______________

Applicant Original Signature

Date

Application Submittal: Please return the completed application to the address below. No photocopies or faxes accepted. If approved, when picking up your card you must present a current photo ID (MA license, State ID, Passport).

You will receive an Application Status Letter in 4 – 6 weeks.

MBTA CharlieCard Store, Downtown Crossing Station

Chauncy Underground Concourse, 7 Chauncy St., Boston, MA 02111

617-222-3200, 617-222-5854/TTY

PART B: TAP CharlieCard Eligibility Criteria

Automatically Eligible Applicants

Applicants who meet one of the criteria below are automatically eligible for a TAP CharlieCard. Simply complete PART A, check off the category below that applies to you, and provide the required information/documents.

Medicare Card holder/Part A & B: Attach photocopy of Medicare Card or current Social Security Benefit Statement verifying Medicare status.

Current customer of THE RIDE: RIDE ID #: ____________________.

Client of DMH/Department of Mental Health (including DMH vendors): Attach original letter, on agency letterhead, from authorized DMH representative (or vendor) verifying status as current client.

Client of DDS/Department of Developmental Services: Attach original letter, on agency letterhead, from authorized DDS representative verifying status as current client.

Veteran with a disability rating 70% or greater: Attach original letter on Veterans Administration letterhead, signed by Veterans Services personnel, specifying disability rating.

Out-of-State/Area reduced fare card holder: Attach copy of your valid, current reduced fare card from your local state/area.

Seniors (65+): No application needed. Go to CharlieCard Store with ID proving age 65+ for a Senior CharlieCard with same reduced fare benefit.

All Other Applicants

If you do not meet one of the above criteria, complete PART A and have your licensed health care professional complete PART C of this application.

IMPORTANT RULES AND CONDITIONS OF USE

Your participation in the reduced fare Transportation Access Pass (TAP) CharlieCard Program is administered in accordance with the MBTA's Privacy Policy. The policy can be found on the MBTA website (www.mbta.com).

Your TAP CharlieCard is subject to inspection or review by MBTA personnel at any time to ensure use by only the authorized person.

An unauthorized person using your TAP CharlieCard is subject to criminal/civil penalties under Chapter 161, Section 113A of the MA General Laws and/or any other applicable MA General Laws. Additionally, you may be disqualified or suspended from participating in the TAP CharlieCard program for allowing unauthorized use of your card.

PART C: Health Care Professional Certification

PART C must be completed by a licensed or certified health care professional, and must be received by the MBTA within 60 days of the health care professional’s signature. Please P-R-I-N-T.

Name of Health Care Professional ________________________________________________

Licensure Title ______________________________Specialty__________________________

License Number _______________________ State Issued ____________________________

Business Address ____________________________________________________________

City _________________________State _______ Zip _________Phone ___________________

IMPORTANT PROGRAM NOTE: The MBTA issues the TAP CharlieCard based on the level of difficulty applicants experience, and the extra planning and effort that may be required, to use public buses/trains/subway due to a physical, psychiatric, intellectual or sensory disability. The TAP CharlieCard is issued to applicants with disabilities who find it moderately/severely difficult to wait for a bus, hear announcements, read visual signs, understand and/or follow directions, board the correct train, maintain stamina, function well in crowds, walk certain distances to transfer between transit modes, etc. The TAP CharlieCard IS NOT ISSUED based on applicant's income level.

1. What is the applicant's disability?

Use GUIDELINE NUMBER(S) from back page_________________________________

Specific Diagnosis __________________________________________

______________________________________________________

2.Does disability cause the applicant difficulty, as described in "Important Program Note" section above, when traveling on the MBTA?

No Yes (Please specify) ___________________________________

________________________________________________________________________

3.Expected duration of disability: Please select only one of the two options below.

_________Temporary: Conditions with potential for improvement within 1 year

_________Permanent: Conditions with no expectation of improvement

4.I certify that the information I have provided above about this MBTA TAP CharlieCard applicant is correct to the best of my knowledge:

_____________________________________ ___________________

Original Signature of Health Care Professional

Date

Guidelines for Health Care Professionals

Please use the categories below to complete Part C HEALTH CARE PROFESSIONAL CERTIFICATION, Item #1: "What is applicant's disability?"

1.

WHEELED MOBILITY DEVICE USERS: Those who,

2. SEMI-AMBULATORY DISABILITIES: Those who, due to

 

due to a disability, require the use of wheeled mobility,

 

a disability, walk with difficulty or insecurity and may or

 

e.g. wheelchair, scooter, etc.

 

 

may not use leg braces, walker, cane, crutches.

 

 

 

 

3.

SEVERE MUSCULOSKELETAL CONDITIONS such

4.

AMPUTATION OF AN EXTREMITY. Please specify

 

as muscular dystrophy, osteogenesis imperfecta or

 

which limb(s) are affected.

 

 

arthritis where functional capacity is limited in ability to

 

 

 

 

 

 

perform usual self care and/or vocational and

 

 

 

 

 

 

avocational activities.

 

 

 

 

 

 

 

 

 

 

 

5.

SEVERE EFFECTS FROM CVA (STROKE): Eligible

6.

SEVERE PULMONARY CONDITIONS (obstructions/

 

conditions include functional motor deficit affecting

 

restrictions) that affect mobility. Those with PFT outcomes

 

any two limbs or ataxia 4 months post cva.

 

< 50% of predicted values (FEV1; FVC; %FEV1; FEF25%-

 

 

 

 

 

75%). Dyspnea occurs during usual activities of daily

 

 

 

 

 

living; climbing a flight of stairs or walking 100 yards; with

 

 

 

 

 

the slightest exertion; or even at rest.

 

 

 

 

7. SEVERE CARDIAC CONDITIONS that result in

8.

PERSONS REQUIRING KIDNEY DIALYSIS

 

moderate or marked restriction in ordinary physical

 

TREATMENT

 

 

 

activity; and may cause fatigue, palpitations, dyspnea

 

 

 

 

 

 

 

 

 

 

 

 

or angina pain when walking one or more level blocks,

9.

VISION IMPAIRMENTS: Those who are legally blind,

 

climbing a flight of ordinary stairs, or even at rest.

 

whose visual acuity in the better eye, after correction, is

 

Classifications: Functional III or IV; Therapeutic C or

 

 

 

20/200 or worse or visual field is contracted. [Applicant will

 

D.

 

 

 

 

 

 

 

be eligible for MBTA BLIND ACCESS CHARLIECARD with MA

 

 

 

 

 

 

 

 

 

 

Commission for the Blind or other Blindness Certification]

 

 

 

 

10.

HEARING-RELATED DISABILITIES: Deafness or

11.

COORDINATION DISABILITIES: Those with a functional

 

hearing loss of 90 db or greater in the 500, 1,000, and

 

motor deficit in any two limbs or who experience

 

2,000 HZ ranges. Please specify the degree of

 

manifestations that significantly reduce mobility,

 

response in each of these ranges.

 

 

coordination and/or perception.

 

 

 

 

 

12.

INTELLECTUAL DISABILITY: Those with I.Q. more

13.

CEREBRAL PALSY: Please include extent of difficulty in

 

than two standard deviations below the norm. Please

 

motor function.

 

 

 

specify I.Q.

 

 

 

 

 

 

 

 

 

 

 

14.

EPILEPSY (CONVULSIVE DISORDER): Please

15.

AUTISM: Please describe nature and severity of disability.

 

include severity and frequency of seizure activity

 

 

 

 

 

 

despite medication.

 

 

 

 

 

 

 

 

 

 

 

16.

NEUROLOGICAL DISABILITIES affecting learning,

17.

PSYCHIATRIC DISABILITIES: This section applies to

 

perceptual and behavioral functioning. Please include

 

those who have a serious, long-term mental illness,

 

nature of condition and etiology.

 

 

that:

 

 

 

 

 

 

 

includes a substantial disorder of thought, memory,

18.

PROGRESSIVE ILLNESSES that impact the

 

 

 

perception, or orientation

 

 

performance of the applicant's organic system so the

 

 

 

 

 

grossly impairs judgment, behavior, capacity to

 

symptoms produced fall within categories 1 – 17

 

 

 

 

recognize reality, or

 

 

above.

 

 

 

 

 

 

 

 

 

greatly impacts ability to meet ordinary/independent

 

 

 

 

 

 

Please indicate applicable categories above that best

 

 

life support needs of food, shelter, clothing,

 

describe impact of illness on applicant's functional

 

 

management of finances, and health care.

 

ability to use public transit buses, subway and trains.

 

Please indicate description and duration of condition.

 

 

 

 

 

 

 

 

 

 

For Internal Use Only:

_______________Staff initials

_______________ Date

 

____Approved: ___ 1 yr ____ 5 yr

____ Eligible for Auto Renew

_____Denied

____Incomplete