50.295: MetroAccess Application

Check the box if you are a current MetroAccess customer and enter your ID Card #.

Check the box if you are a current Reduced Fare customer and enter your Reduced Fare ID Card #.

Check the box if you have access to the internet and/or have an email account.

Common mistake: In Part A, enter your Last, First and Middle Initial. Copies, faxes or scans will not be accepted.

Enter the Street Address and Apartment #, then the City, State, Zip and County.

Check Male or Female for Gender, then enter the Date of Birth and E-mail.

Enter the Primary phone number and check Home, Cell Phone or Work for it, then do the same for the Secondary phone number.

In case of an emergency, enter the Name of who should be notified, then the Relationship and Phone.

Check Yes or No: do you require the use of a mobility device when traveling?

Check all that apply: Manual Wheelchair, Support Cane, Portable Oxygen, Crutches, Power Wheelchair or Scooter up to 48" x 30" and no more than 800 pounds when occupied, Walker, White Cane (for Blind/ Low-Vision), or Other.

Check Yes, No or Sometimes: do you use a service animal? If yes, describe the type of animal and what service(s) the animal was trained to perform.

Sign Part A with the Original Signature of Applicant and the Date to certify that all information contained in part A of this application was completed by you or your appointed representative and is true. Under 18, enter the Signature of Parent or Guardian.

In the Applicant's HIPAA Authorization, fill in the line to authorize the healthcare provider completing this application to release to the Washington Metropolitan Area Transit Authority (Metro) any protected health information about your disability in order to verify your eligibility for Metro Services for People with Disabilities.

You also authorize the release of further information should it be needed for this application for a period of 60 days from the date of your signature on part A of this application.

Enter your Applicant Signature and the Date.

One of these health care providers must certify the application: Physician, Physician's Assistant, Certified Nurse Practitioner, Optometrist (visual disabilities only), Podiatrist (disabilities of the foot and ankle only) or Licensed Clinical Psychologist (Psychiatric disabilities only).

The healthcare provider (not the applicant) must complete and certify all of the sections of Part B.

Write the Applicant's name on the line: the applicant is being referred for a brief functional assessment to determine eligibility for Metro services for people with disabilities.

Print the Name of Health Care Provider.

Enter the Phone and the License Number/State Issued.

Enter the Street Address & Suite # and the City, State, Zip.

Enter the Specialization and the Written Diagnosis(es) and ICD-9CM and/or DSM Code(s).

Detail how the applicant's disability(ies) impact their ability to board, navigate and travel independently on the accessible fixed route system. Be as specific as possible.

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

Common mistake: The healthcare provider signs with an original hand signature, not a signature stamp, and enters the Printed Name and Date, to certify that the questions in Part B are completed and the information provided is correct.

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. Please have your completed application at hand when you call.

Phone lines are open Monday, Wednesday - Friday from 8:30 AM - 4:00 PM, and Tuesday, 8:30 AM to 2:30 PM and are closed from 11:50 AM- 1:00 PM daily. Hours are subject to change without notice.

24 hours notice is required 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.

Complete the authorization if you are providing legal authority to another party to complete this application and act as your agent in the processing of this application. The authorization is only to be used when an applicant is not able to otherwise give consent for assistance and information sharing.

Write who you are appointing to help you apply for MetroAccess service. For this purpose only, he or she has the authority to act on your behalf, including scheduling appointments, completing paperwork, and providing information about you to WMATA (Metro), so long as it relates to your application for the service.

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

Then enter your Signature, Date and Printed Name.

The agent writes the Agent's Name and Applicant's Name and agrees to help with the application. Either the agent, or another person from the agent's organization, will come with the applicant to the eligibility appointment and assist him/her. The agent then enters the agent's Signature and Date.

The ADA requires Metro to provide notification of an applicant's eligibility status within 21 days of submitting a completed application. If, for any reason, it takes longer than that to process the determination, the applicant will be eligible to use MetroAccess until Metro completes the eligibility process. This is called "presumptive eligibility."

If 21 days have passed since Metro received the completed application the applicant will be automatically granted eligibility for MetroAccess until the review process is completed.

Contact the office within 60 days of the date of the healthcare provider's signature. Applications more than 60 days old will not be accepted.

Do not mail or fax the application. Applications that are mailed will be returned to the applicant with instructions to contact the Transit Accessibility Center. 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. The Transit Accessibility Center is at 655 Virginia Avenue, SW Washington, DC 20024 (L'Enfant Plaza Metro Station). All assessments are by appointment only.