Metro Mobility Minneapolis Details

Are you considering applying for Metro Mobility? Do you want to know what is required of you? In this blog post, we will outline everything that you need to know about the Metro Mobility application form. We will provide tips on how to complete the form and what documentation you will need to submit.

If you'd like to get a few specific details when it comes to the PDF you'll work with, here is the data you can look at prior to filling out the metro mobility application.

QuestionAnswer
Form NameMetro Mobility Application
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesapplication metro mobility, metro mobility application, mobility metro application, mobility application metro

Form Preview Example

APPLICATION INSTRUCTIONS

All applicants must submit a complete application which includes BOTH FORMS

(1)The Certiication Questionnaire Form

(2)The Professional Veriication Form

STEP 1 COMPLETE THE CERTIFICATION QUESTIONNAIRE

The Certiication Questionnaire should be illed out by

the applicant or the applicant’s advocate. The form must be illed out in its entirety. It should be signed by the applicant or the applicant’s guardian and anyone who assisted the applicant in completing the application.

CERTIFICATION

QUESTIONNAIRE

Americans with Disabilities Act (ADA) | Paratransit Eligibility

1.

See application Instructions

We do not

2.

If you have additional questions call Metro Mobility

accePt

 

Customer Service at (651) 602-1111 voice, (651) 221-9886 TTY.

aPPlications

3. This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED

by fax

 

PROFESSIONAL VERIFICATION.

 

 

 

 

This application and future written information are available in large print. Does large print better suit your needs?

PART 1 APPLICANT DATAPlease Print or tyPe

Name: ______________________________________________________________________________________

STEP 2 COMPLETE THE PROFESSIONAL VERIFICATION FORM

The Professional Veriication Form must be completed by one of the following professionals who are familiar with the applicant’s condition:

Physicians or Psychiatrists

Occupational Therapists

Psychologists

Physical Therapists

Licensed Independent Social Workers (LISW, LICSW)

Recreational Therapists

Speech/Language Pathologists

Certiied Orientation and Mobility Specialists

Registered Nurses (RN)

Doctors of Chiropractic (DC)

ELIGIBILITY APPLICATION

PROFESSIONAL VERIFICATION

Americans with Disabilities Act (ADA)

1.

Complete and sign the “Authorization to Release Information”.

We do not

2.

Send to your designated professional.

accePt

3.

Wait for the professional to return this form to you.

aPPlications

 

Check back with your professional if you don’t receive your information.

by fax

4.This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED CERTIFICATION QUESTIONNAIRE.

SECTION A RELEASE INFORMATION

Please Print or tyPe

AUTHORIZATION TO

 

 

 

 

 

 

(WHEN COMPLETE SEND TO THE PROFESSIONAL YOU NAMED)

Applicant’s Name: First

Middle Initial

Last

Birth Date:______/______/______

 

 

Applicant’s Address: ________________________________________________ Apt.#:____________________

City: ___________________________________________ State:_____________ Zip Code: ________________

Applicant’s Telephone Number (

) ______________________________

I authorize the following professional to release to the MMSC speciic information as requested. It is my understanding that the information released will be used solely to determine my ADA paratransit eligibility. I understand that I may revoke this authorization at any time. Unless revoked, this form will allow that professional listed below to release information described for six months after the date appearing below.

Name of Professional: _______________________________________________ Title:_____________________

Applicant’s Signature: ____________________________________________ Date: ______/______/______

Guardian’s signature required if the applicant is not his/her own guardian,

Guardian’s Signature:_____________________________________________ Date: ______/______/______

To complete the Professional Veriication Form

1.Complete and sign the Authorization to Release Information.

2.Send the Professional Veriication Form to your designated professional.

3.Wait for your professional to return the Professional Veriication Form to you. Check back with your professional if you have not received the form back in a timely manner.

STEP 3 SUBMIT BOTH FORMS TOGETHER

Submit both the Certiication Questionnaire and the Professional Veriication Form in the same envelope to

Metro Mobility Service Center

390 N. Robert Street

Saint Paul, MN 55101-1805

WE DO NOT ACCEPT APPLICATIONS BY FAX OR E-MAIL

See additional info on back

 

 

STEP 4 IN-PERSON ASSESSMENT

Usually the forms provide Metro Mobility Staff with all of the information needed to make a determination on eligibility. Sometimes however more information is needed. When this happens an applicant may be asked to come in for an “in-person assessment.”

This assessment may include:

A conversation about the applicant’s current mobility. The Metro Mobility evaluator will talk with you about how you currently get around.

A pretend bus trip on the computer. This standardized test is designed to measure a person’s cognitive ability to use regular ixed-route transit. (Functional Assessment of Cognitive Transit Skills or FACTS for short.)

A walk outside or through the skyway. This will help determine things such as physical ability to get to the regular ixed-route bus as well as memory and landmark recognition.

A standard walking and balance test. This standardized test measures a person’s risk of falling. (Tinetti Gait and Balance Test.)

PLEASE NOTE THAT APPLICANTS WHO NEED TO COME IN FOR IN-PERSON ASSESSMENTS WILL STILL HAVE THEIR APPLICATIONS PROCESSED WITHIN 21 CALENDAR DAYS.

COMMON ISSUES

In order to make a determination within 21 calendar days the Metro Mobility Service Center must have a complete application. There are several things which may cause an application to be incomplete. By double checking these things PRIOR to submitting your application you may avoid delays in processing.

1.One of the forms is missing. Your application must contain both the Certiication Questionnaire and the Professional Veriication. Please ensure both are submitted in the same envelope.

2.One of the forms is not signed. Both the Certiication Questionnaire and the Professional Veriication must be signed. If either the applicant or the professional forgets to sign the form it is considered incomplete.

3.The professional credentials are missing. Professionals must include their titles and credentials when signing the Professional Veriication.

Jane Doe X (Incomplete) Jane Doe M.D.

(Complete) Jane Doe R.N.

(Complete)

AN INCOMPLETE APPLICATION WILL BE RETURNED TO THE APPLICANT ONE (1) TIME. IF IT IS SUBMITTED A SECOND TIME AND IS STILL INCOMPLETE IT WILL BE HELD FOR 60 DAYS BY THE METRO MOBILITY SERVICE CENTER BEFOREIT IS DISCARDED.

APPLICATIONS MUST BE PROCESSED WITHIN 21 CALENDAR DAYS. IF YOUR PROPERLY COMPLETED AND SUBMITTED APPLICATION IS NOT PROCESSED WITHIN 21 DAYS, YOU WILL BE GRANTED PRESUMPTIVE ELIGIBILITY FOR METRO MOBILITY SERVICE UNTIL YOUR APPLICATION IS PROCESSED.

Questions? Please call 651-602-1111

CERTIFICATION

QUESTIONNAIRE

Americans with Disabilities Act (ADA) | Paratransit Eligibility

1.See application Instructions

2.If you have additional questions call Metro Mobility

Customer Service at (651) 602-1111 voice, (651) 221-9886 TTY.

3.This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED PROFESSIONAL VERIFICATION.

WE DO NOT ACCEPT APPLICATIONS BY FAX

This application and future written information are available in large print. Does large print better suit your needs?

PART 1 APPLICANT DATA

PLEASE PRINT OR TYPE

Name: ______________________________________________________________________________________

FirstMiddle InitialLast

Street Address: ____________________________________________________ Apt.#:____________________

City: ______________________________________________________________ Zip Code: ________________

Day Telephone: (

) ________________________ Evening Telephone: (

) ________________

Email Address: _____________________________________________________

 

 

I prefer communication via email: ____Yes ____No

 

 

Birth Date:______/______/______

 

 

Do you have a Minnesota state ID card or Minnesota driver’s license?

Yes

No

ID # ______________________________ License # ______________________ Expiration Year: __________

Mailing Address (if different from above)

Street Address: ____________________________________________________ Apt.#: __________________

City: ______________________________________________________________ Zip Code: ______________

Emergency Contact Person

Name: _____________________________________________________________________________________

First

Middle Initial

Last

Day Telephone: (

) _______________________ Evening Telephone: (

) _______________

1.Are you able to travel in an automobile? ____Yes ____No

2.If you use a wheelchair or scooter:

Is it more than 30 inches wide? ____Yes ____No

Is it more than 48 inches long? ____Yes ____No

Is the combined weight of device and occupant more than 600 pounds? ____Yes ____No

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3. Which of the following assistive devices, if any, do you use? (Please check all that apply.)

Cane

Manual Wheelchair

Boarding Chair

Prosthesis

White Cane

Powered Wheelchair

Service Animal

Communication Aid

Walker

Powered Scooter/

Portable Oxygen

Other (please describe):

Crutches

Cart

Transfer Board

 

If you selected Wheelchair or Scooter, would you prefer/need to use the device while riding in Metro Mobility Vehicles? ____Yes ____No ____Sometimes

4.Does your health condition/disability require you to use Metro Mobility service:

Seasonally (Nov. - Apr.)

Permanently

Temporarily

 

If temporarily, for how long?

Week(s)

Month(s)

5.Does your health condition/disability change from day to day in ways that occasionally disrupts your ability to use regular-route city bus service? ____Yes ____No

If yes, please explain: ______________________________________________________________________

6.When using Metro Mobility service, does your health condition/disability require you to travel with someone to assist and/or supervise you? ____Yes ____No

PART 2 QUESTIONS ABOUT USING

REGULAR-ROUTE PUBLIC TRANSIT

Complete Part 2 even if you are unable to use regular-route city bus service. This information will assist us in determining how your disability/health condition affects your ability to use regular-route city bus

service.

7. Do you now independently use regular-route city buses? ____Yes ____No ____Sometimes

If “Yes” or “Sometimes,” how many times?

per week

per month per year

Which of the following best describes how you use regular-route city buses?

To travel to and from one destination only

To travel to and from a few destinations

To travel to and from many different destinations

Explain what prevents you from independently using regular-route city bus.

8. Have you ever had training to use the regular-route city buses? ____Yes ____No

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9. Using a mobility aid or on your own, how far are you able to travel without the assistance of

another person?

3 blocks

6 blocks

 

9 blocks or more

less than 3 blocks

10.I can wait for a regular-route city bus (check all that apply):

Only if there is a bench or shelter

Up to 15 minutes

More than 15 minutes

11.Please check all the categories below as they relate to your ability to use regular-route city buses:

 

I am:

Yes

No

Sometimes

A.

Able to tolerate very hot or very cold weather

 

 

B.

Able to recognize destinations, bus stops, or landmarks

 

 

C.

Able to tolerate air pollution (smog, fumes, perfume)

 

 

D.

Free from night blindness

 

 

E.

Able to recognize printed information

 

 

F.

Able

to hear and process spoken words or auditory information

 

 

G.

Able to communicate needs

 

 

H.

Able to follow directions

 

 

I.Able to deal with unexpected situations or changes in routine

(example: bus detours)...................................................................

J.Able to safely and effectively travel through crowded and/or

complex facilities............................................................................

K. Able to recognize changes in terrain..................................................

L.Able to travel independently along sidewalks and other

pedestrian ways ..............................................................................

M. Able to cross streets independently...................................................

N. Able to ind the correct bus stop .......................................................

O. Able to identify the correct bus..........................................................

P. Able to get on and off a bus using the lift if necessary......................

Q. Able to deposit fare into the fare box or show bus pass ...................

R.Able to get to a seat/wheelchair position and remain seated

during a bus trip ..............................................................................

S. Familiar with what to do if I miss my bus...........................................

If you checked “No” or “Sometimes” to any of the items in question 11, please explain:

More Space Provided On The Next Page

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PART 3 APPLICANT SIGNATURE

The information provided on this form is private data and is used to determine ADA paratransit eligibility. The ability to determine your eligibility is based on receiving all of the information requested on this form. All medical or locational information pertaining to application for or users of ADA paratransit service is private. Any other information cannot be released to anyone else, unless the applicant or user authorizes the release in writing. If you are determined ADA paratransit eligible, information about your eligibility status will be entered into a database maintained by the Minnesota Department of Public Safety, Driver and Vehicle Services Division. This information could be used by Drivers License Division of the Depart- ment of Public Safety to (1) Reexamine your driving ability or, (2) Demand that you surrender your license if a severe disabling condition has developed since the current license was issued.

I certify that all information on this application form is accurate. I understand that misinformation or misrepresentation of facts will be cause for disqualiication or rejection of my ADA eligibility. I also understand that additional information relating to my health condition or disability may be required to determine eligibility. This information may be obtained through an in-person assessment or by requesting information from a professional who understands my health condition or disability. Additional information will be required only when the information provided on the application form does not clearly determine ADA paratransit eligibility.

Applicant’s Signature:_____________________________________________ Date:______/______/______

*If the applicant is not his/her own guardian, the following information about the guardian is required:

Guardian’s Name: (please print) _______________________________________________________________________________

 

First

Middle Initial

Last

Day Phone: (

) ______________________________________________________

Guardian’s Signature: _____________________________________________ Date:______/______/______

*If someone other than the applicant or the applicant’s guardian is preparing this form, please provide the following information about the preparer:

Name: (please print) _________________________________________________________________________________________

 

First

Middle Initial

Last

Day Phone: (

) ______________________________________________________

Preparer’s Signature:______________________________________________ Date:______/______/______

4

ELIGIBILITY APPLICATION PROFESSIONAL VERIFICATION

Americans with Disabilities Act (ADA)

1.Complete and sign the “Authorization to Release Information”.

2.Send to your designated professional.

3.Wait for the professional to return this form to you.

Check back with your professional if you don’t receive your information.

4.This form is incomplete if it is NOT ACCOMPANIED BY COMPLETED CERTIFICATION QUESTIONNAIRE.

WE DO NOT ACCEPT APPLICATIONS BY FAX

AUTHORIZATION TO

PLEASE PRINT OR TYPE

SECTION A RELEASE INFORMATION

 

 

 

 

(WHEN COMPLETE SEND TO THE PROFESSIONAL YOU NAMED)

 

 

 

Applicant’s Name: First

Middle Initial

Last

Birth Date:______/______/______

 

 

Applicant’s Address: ________________________________________________ Apt.#:____________________

City: ___________________________________________ State:_____________ Zip Code: ________________

Applicant’s Telephone Number (

) ______________________________

I authorize the following professional to release to the MMSC speciic information as requested. It is my understanding that the information released will be used solely to determine my ADA paratransit eligibility. I understand that I may revoke this authorization at any time. Unless revoked, this form will allow that professional listed below to release information described for six months after the date appearing below.

Name of Professional: _______________________________________________ Title:_____________________

Applicant’s Signature: ____________________________________________ Date: ______/______/______

Guardian’s signature required if the applicant is not his/her own guardian,

Guardian’s Signature:_____________________________________________ Date: ______/______/______

1

SECTION B METRO MOBILITY PROFESSIONAL VERIFICATION FORM

Dear Health Care Professional:

You are being asked to provide information regarding this individual’s disability. The Federal Law is very speciic about ADA para-transit eligibility. The law restricts eligibility to individuals who,

1.as a result of their disability, cannot board, ride, or disembark from a regular ixed route bus or light rail car or

2.have a speciic impairment-related condition which prevents them from getting to or from a bus stop.

PLEASE NOTE: This does not include persons who ind it dificult or uncomfortable to get to and

from bus stops. In providing information you should consider only the presence of a disability or health condition and not the applicant’s age or economic status.

THIS SECTION MUST BE FILLED OUT FOR ALL APPLICANTS

GENERAL INFORMATION

Describe the diagnosed disability you are currently treating this individual for: _____________________

____________________________________________________________________________________________

• Describe any other health conditions or disabilities with which this individual is diagnosed:__________

____________________________________________________________________________________________

Date of onset ____/____/____

Date of last visit ____/____/____

How long have you worked with the individual? Since ____/____/____

Is disability temporary ________ or permanent ________ ?

If permanent is disability progressive? ____Yes ____No

If temporary please give best estimate of rate of recovery. ___________________________________

• Is therapy part of treatment? ____Yes ____No If yes, give brief description ______________________

____________________________________________________________________________________________

• Do temperature extremes affect the individual?

(Ex. Heat index of more than 85 degrees or wind chill less than 10 degrees) ____Yes ____No

If yes, how so? _________________________________________________________________________

• Please list all medications. _____________________________

____________________________

_____________________________

____________________________

_____________________________

____________________________

Is this individual compliant with taking medications? ____Yes ____No

Does the individual currently uses regular route public transportation? ____Yes ____No ____Not Sure

Is the individual’s judgment impaired ____Yes ____No

Is behavioral inhibition impaired? ____Yes ____No

Can the individual walk? ____Yes ____No

• Does the individual use a mobility aid? ____Yes ____No Please list ____________________________

____________________________________________________________________________________________

2

How long has individual been using the device(s)? _____________________________________________

____________________________________________________________________________________________

• How far can the individual travel without the assistance of another person?

3 blocks

6 blocks

9 blocks or more

less than 3 blocks

With treatment/therapy will this distance increase? ____Yes ____No

Please indicate the expected distance after treatment/therapy:

3 blocks

6 blocks

9 blocks or more

less than 3 blocks

Give best estimate of length of time required to achieve this improvement. _______________________

____________________________________________________________________________________________

PLEASE COMPLETE ONLY THOSE SECTIONS THAT APPLY TO THIS INDIVIDUAL

NEUROLOGICAL IMPAIRMENT/HEAD INJURY

Does the individual experience seizures? ____Yes ____No Date of last seizure ______/______/______

Please give no. of seizures ________ and frequency ____________________________________________

What type(s) of seizures does patient experience_______________________________________________

Does individual experience auras? ____Yes ____No

Is the individual’s judgment impaired? ____Yes ____No

Is behavioral inhibition impaired? ____Yes ____No

Does judgment and inhibition impairment prevent the individual from independently traveling outside the home or immediate environment? ____Yes ____No

When traveling independently does the individual have the ability to: (check all that apply)

Get help if lost

Recognize & avoid danger

Cross streets safely

Follow written directions

Communicate needs

Process information

Understand and follow schedule to get places on time

• Is there history of Brain Injury ____Yes ____No. Date of injury______/______/______

VISUAL IMPAIRMENT

Please provide visual acuity measurements and visual ield readings for both eyes. OS: __________________________ OD: ________________________________

Does the individual require any accommodations, adaptations, low vision aids, etc? Please list:

____________________________________________________________________________________________

____________________________________________________________________________________________

• How does the individual’s visual impairment affect their ability to move about in the environment?

____________________________________________________________________________________________

____________________________________________________________________________________________

• Has the individual received any orientation & mobility (O&M) training? ____Yes ____No

3

Questions? Please call 651-602-1111

 

• Does the individual experience any of the following:

 

 

Auditory hallucinations

Visual hallucinations

Delusions

Disassociation

Does this prevent the individual from being oriented to person, place, and time? ____Yes ____No

Is the individual currently being treated for any of the following:

Anxiety

Depression

Panic attacks

Schizophrenia

Other: _____________________

 

 

For anxiety panic attacks please indicate on average the frequency and length of panic attacks. Per day________ Per week________ Per month________ Per year________

Approx. duration: ________

What technique(s) and/or skills is the individual utilizing to assist in coping with the above issue(s)?

Visualization

Relaxation techniques

Positive self-talk

Aroma therapy

Other:______________________

 

 

Are these techniques effective in reducing symptoms? ____Yes ____No

Is there a history of Electroconvulsive Therapy (ECT)? ____Yes ____No ____Unknown

COGNITIVE/MENTAL IMPAIRMENTS

Please list IQ score and GAF score if known. IQ = ___________ GAF = ___________

Please describe the functional limitations caused by this impairment?

___________________________________________________________________________________________

___________________________________________________________________________________________

Is the individual’s judgment impaired? ____Yes ____No

If yes, please describe to what extent or give an example.______________________________________

_________________________________________________________________________________________

• Is the individual able to live independently? ____Yes ____No

Additional Comments: ____________________________________________________________________

___________________________________________________________________________________________

MMSC Staff will make the inal determination of the applicant’s eligibility

Doctor/Health Care Professional Signature: _________________________________________________

PLEASE RETURN FORM TO APPLICANT PLEASE PRINT so that we may contact you if needed Name of Professional: ______________________________________________ Date: ______/______/______

Title: _______________________________________________________________________________________

Street Address:______________________________________________________________________________

City: _____________________________________ State: ________ Zip Code: _________________________

Telephone Number: (

) ____________________________ Fax: (

) _____________________

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