Metro Access Applicaiton Form – Fill Out and Use This PDF

Application for

MetroAccess Door-to-Door Paratransit Service

For People with Disabilities

DO NOT MAIL OR FAX APPLICATION

Transit Accessibility Center

6005th Street, NW Washington, DC 20001

(Between Chinatown/Gallery Place and Judiciary Square Metro Stations)

(202)962-2700 & select option #5 TTY (202) 962-2033

All Assessments are by Appointment Only

Thank you for youred oninterMetro’sst in Mdeterminationtro services offoryourpeopleeligibilitywith disabilities. The following services

(A)Reduced Fare Program for People with Disabilities – Eligible people with disabilities

travel on accessible Metrobus and Metrorail for half the regular (rush hour) fare at all times. This

program is available for people with disabilities who use the accessible Metrobus and Metrorailare available bas:

system as their primary travel option. For more information on the Reduced Fare program or to

obtain an application please visit our website atunder the section titled (ow

dohttp://www) get a Metro.wmataDisability.com/accessibility/metroaccess)D Card?_eligibility.cfm

or call (202) 962-2700 and select option 1 from the phone

(B)MetroAccess – Door-to-door, shared ride public paratransit service for people with disabilities who are unable to use regular accessible Metrobus and Metrorail public transportation

for some or all of their public transportation due to a disability. The Americans with Disabilities Act (ADA) outlines specific criteria to determine eligibility for paratransit service and an application anmenu.

in-person assessment is required. MetroAccess operates throughout the metropolitan area where there is regularnd PrincebusGeorge’sand/or railCountyservinceMaryland;. Service isArlingtonprovidedCounty,in Washington,Fairfax County,DC; MontgomeryCity of County a

Alexandria, City of Fairfax, and City of Falls Church in Virginia.

To apply for this service you and your healthcare provider must complete this application. Please read and follow the instructions on page 2.

Application revision date: July 2012

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Instructions

Step 1: Read the entire application and complete Part A.

Step 2: Read Accessible Transportation Options for People with Disabilities and Senior Citizens in

the Washington, DC Metropolitan Area, included with this application packet or also available at http://www.wmata.com/accessibility/doc/Accessible_Transportation_Options.pdf

Step 3: Take the entire application to a healthcare provider holding active licensure or credentials in certifythe areatheofapplication:your disabilityPhysician,to completePhysician’sPart BAssistant,. One of the following health care providers must

Certified Nurse Practitioner, Optometrist

(visual disabilities only), Podiatrist (disabilities of the foot and ankle only) or, Licensed Clinical Psychologist (Psychiatric disabilities only). It is your responsibility to ensure the original signed and completed application is received by the Metro Transit Accessibility Center on the day of your appointment.

Step 4: Upon completion of the application, call 202-962-2700 and select option 5, ( TTY 202-962-2033) to conduct a pre-assessment interview. At that time, a determination will be made as to the type of

appointment and/or assessment that will be required, and an appointment will be made for you. officePleasewithinhave 60yourdayscompletedof the dateapplicationof the healthcareat handprovider’swhen yousignaturecall. Also. Applicatensure you contact the

ions more than 60

days old will not be accepted. You will be instructed to bring your completed original application with you to the appointment. Do not mail or fax the application. NOTE: We require 24 hours notice if you need to cancel your appointment, except in case of a verified emergency. If you miss or cancel 2 appointments you will be required to complete a new application and be required to wait 120 days to reapply.

Copies, faxes, and scans will not be accepted. Applications with missing information will not be accepted and will be returned to the applicant without processing. Applications that are mailed will be returned to the applicant with instructions to contact the Transit Accessibility Center.

Step 5: Metro will determine your eligibility based on how your disability impacts your functional abilities to use the accessible Metrobus and Metrorail public transportation system. Financial need is not a criterion for MetroAccess eligibility. All assessments take place at the Metro Transit Accessibility Center. If you use a mobility aid, please bring it with you to the assessment. If transportation is needed, advise the Metro Transit Accessibility Center representative at the time of your telephone interview.

If you have questions or need additional information, please contact the Metro Transit Accessibility Center at 202-962-2700 and select option 5, TTY 202-962-2033 or e-mail eligibility@wmata.com. Please do not bring children to the appointment unless the child is the applicant. Please note that the minimum age to apply for the service is 5 years old. The office is open Monday, Wednesday

-Friday from 8:00 AM - 4:00 PM, and Tuesday, 8:00 AM to 2:30 PM. Hours are subject to change without notice so Please call in advance. Phone lines open at 8:30 on all days.



Application revision date: July 2012

Page 2 OF 9

I am a current MetroAccess customer. MetroAccess ID Card # ________________________

I am a current Reduced Fare customer. Reduced Fare ID Card # ____________________

I have access to the internet and/or have an email account.

Part A: APPLICANT INFORMATION AND RELEASE (Copies, faxes or scans will not be accepted)

Last Name______________________________ First Name______________________________ Middle Initial ________

Street Address:	Apartment #:
City, State, Zip:	County or City:

Gender: Male Female Date of Birth: ____/______/________ E-mail:_________________________________

Primary phone number: ( ) _______________________________ Home Cell Phone Work

Secondary phone number: ( ) _____________________________ Home Cell Phone Work

In case of an emergency, who should be notified?

Name:

Relationship:

Mobility Devices: Do you require the use of a mobility device when traveling?  No Yes

Check all that apply: Man	al Wheelchair	 Support C	e Portable Oxygen
Power Wheelchair			800 pounds when occupied
CrutchesWalkerorScooterWhiteupCane(forto 8 xvisually0 andimpaired)no more than Other: _____________________________
Do you use a service animal?	No Yes	Sometimes If yes, please describe the type of
animal and what service(s) the animal was trained to perform:

I certify that all information contained in part A of this application were completed by me or my appointed representative and are true.

Original Signature of Applicant: __________________________________________ Date:_________________________

(Under 18, Signature of Parent or Guardian)

Application revision date: July 2012

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AUTHORIZATION TO HELP ME APPLY FOR METROACCESS SERVICES

Please complete the authorization below if you are providing legal authority to another party to complete this application and act as your agent in the processing of this application.

** This form is only to be used when an applicant is not able to otherwise give consent for

Applicant’sassist ce andNameinformation sharing.

Applicant’s Address______________________________________________________

_____________________________________________________

I would like to apply for MetroAccess door to door paratransit service.

I am appointing _____________________________to help me apply for MetroAccess service. For this

purpose only, he or she has the authority to act on my behalf, including scheduling appointments, completing paperwork, and providing information about me to WMATA (Metro), so long as it relates to my application for MetroAccess service. Metro may release any information it has about me upon request, to this person, including health care information, so long as it relates to my application for services. For this purpose only, my agent may request, receive, and review any information, oral or written, regarding my physical or mental health, including but not limited to, medical and hospital records and other protected health information, and consent to disclosure of this information.

For all purposes related to this document, my agent is my personal representative under the Health Insurance Portability and Accountability Act (HIPAA) and is entitled to request, receive, and review protected health information: any information, oral or written, regarding my physical or mental health, including but not limited to medical and hospital records, and other protected health information. My agent may also consent to disclosure of this information.

Application revision date: July 2012

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This agreement expires: (Select one from options below.)

_____ At the end of my appointment on __________________; or

_____ At the end of my MetroAccess certification process; or

_____ At the end of my MetroAccess certification and any applicable appeal process.

In any event, this agreement would expire no later than one year from when it is signed. I can cancel this agreement at any time by telling the person and calling Metro to inform them that this authorization is no longer valid.

Signature

Date

Printed Name

I, ________________________________________________, agree to help ______________________________ with

(Agent’s Name

Applicant’s Name)

his/her application for MetroAccess services. Either I, or another person from my organization, will come with the applicant to their eligibility appointment and assist him/her.

Signature

Date

Printed Name

Application revision date: July 2012

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Part B: HEALTH CARE PROVIDER CERTIFICATION

holding active licensure or credentials in the area of the applicant’s disability orA healthcarethe applicant’sproviderprimary care provider as outlined on page 2 must complete Part B.

Your patient has requested eligibility for MetroAccess services. MetroAccess is a door to door,
uniquely qualified to clarify his or her functional					the applicant’s healthcare provider you are
shared ride paratransit service for people whose disability(ies) prevent them from riding the fixed
route accessible system, all or part of the time. As						icant’s functional abilities we
that you the healthcare provider not the applicant
				abilities and l mitations to ride the M			tro	’s require
accessible bus and rail system. In order to determine this appl
travel independently onhow the applicant’s						complete and certify all of the following
sections. Please detail			disability(ies) impact their ability to board, navigate and
		the accessible fixed route system. Please be as specific as possible

Applicant’s HIPAA Authorization:

I _________________________________authorize the healthcare provider completing this application to

release to the Washington Metropolitan Area Transit Authority (Metro) any protected health information about my disability in order to verify my eligibility for Metro Services for People with Disabilities. I also authorize the release of further information should it be needed for this application for a period of 60 days from the date of my signature on part A of this application.

____________________________________________________________ (Applicant’s name) is being referred for a brief

functional assessment to determine eligibility for Metro services for people with disabilities.

1.Name of Health Care Provider: (Please print)____________________________________________________

2.Phone: ( ) _______________________

3.License Number/State Issued: ___________________________

4.Street Address & Suite #: ________________________________________________________________________________

5.City, State, Zip: ____________________________________________________________________________________________

6.Specialization: ____________________________________________________________________________________________

7.Written Diagnosis (es) and ICD-9CM and/or DSM Code(s): ______________________________________

__________________________________________________________________________________________________________________

8.HYPERTENSION: Eligibility for service is determined by a functional assessment, which is

conducted by a certified/licensed therapist with the Transit Accessibility Center. Applicants may be required to walk/travel up to 1/2 mile. In order to ensure the safety ofe applicant’sthe applicant,restinga bloodB/P is pressure (B/P) reading is taken prior to starting the assessment. If th

Application revision date: July 2012

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160/100 or higher, the assessment will be suspended pending certification by the health care provider that the applicant can complete the assessment. If you are currently treating the applicant for hypertension and certify that he/she is cleared to complete the functional assessment, we may proceed without referring the applicant back to you for evaluation and certification.

9.Are you currently treating this applicant for Hypertension? No Yes

10.Applicant can complete the assessment as described above if B/P does not go above a reading of: ______________________

11.If applicant has a seizure disorder or epilepsy have they had a tonic-clonic seizure within the past 4 months?

No Yes N/A

12.Does the applicant require a Personal Care Attendant (PCA) when traveling on public transportation?

No Yes

13. Does the applicant require any of the following mobility aids listed in question 14?

No Yes

14.Check all that apply: Manual Wheelchair Support Cane Portable Oxygen

Power Wheelchair or Scooter CrutchesWalkerWhite Cane (visually impaired) Other: __________________

15. What is the expected duration of the disability? (Please initial appropriate box)

_____Short-Term: Conditions that last at least 90 days, but are likely to improve within one year.

____Long-Term: Conditions with absolutely little expectation of improvement

16. Does this applicant’s disability(ies) prevent him/her from independently using the accessible Metrobus and Metrorail system?

No Yes the disability or health condition impact the applicant’s ability to travel If yes, HOW does

independently from one location to another on the accessible Metrobus and Metrorail system?

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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17.If this applicant is currently on medication(s), will the side effects of this significantly reduce or hinder his/her ability to independently ride the accessible Metrobus and Metrorail system?

No Yes N/A

applicant’sIf you selectedabilityyestoforusethisthequestion,accessiblepleasefixedexplainroute bushowandtherailsidesystem:eff cts would hinder this

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Based on the applicant’sENVIRONMENTALdisability ies ISSUES, pleaseTHATtell usAFFECTif followingTHEenvironmentalAPPLICANT factors affect his/her ability to ride Metro’s accessible bus and rail system.

18.Would extremes in temperature affect this applicant’s ability to ride the accessible Metrobus or Metrorail?

No Yes

If yes, please explain the effect and the extent of the limitation(s)

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

19. Would ice and/or snow affect this applicant’s ability to ride accessible Metrobus or Metrorail system?

No Yes

If yes please explain the effect and the extent of the limitation(s)

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

20. Would poor air quality affect this applicant’s ability to ride Metrobus or Metrorail? Yes No If yes please explain the effect and the extent of the limitation(s). NOTE: If applicant suffers from Asthma, please indicate if the applicant has been on systemic medication for the immediate past 6 months OR has been required to use fast acting inhalers for three or more episodes per week for the immediate past six months

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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21.In your medical opinion what other factors related to the applicant’s disability(ies) affect his/her ability to ride the accessible Metrobus or Metrorail?

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

HEALTH CARE PROVIDER SIGNATURE PAGE

I certify that I have completed the questions in Part B and that the information provided is correct.

Original Signature of Physician/Healthcare Provider: ______________________________________________

(Note: Must be original hand signature, not signature stamp)

Printed Name_________________________________________________________Date: _____________________

False certification may be reported to the licensing agency under District of Columbia Code Annotated,

Section 2-3305.15, Code of Virginia 54. 1-2915, or Maryland Health Occupations Code Annotated 14-404 or appropriate code for state of license. Metrortification,reservesmakethe rightthe finalto: (1)determinationv ify the validityon anofapplicant’sthe licenseeligibilityof the health care provider providing the ce

for Metro services for people with disabilities, and (3) retain a copy of this application.

Application revision date: July 2012

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