Metrolift Application Houston Details

The Metrolift application form can be found on the CTA website. It is a required document to apply for Reduced Fare or Free Ride privileges. The form is also needed when reapplying, or if you are requesting a transfer of benefits from another person. In addition to your name and contact information, you will need to provide your date of birth, the last four digits of your social security number, and copies of applicable IDs. There is also a section for income verification, so have your most recent tax return prepared beforehand. Filling out the Metrolift application form accurately and completely will help ensure a quick approval process.

You will see info about the type of form you wish to fill out in the table. It can show you how long it will need to fill out metrolift application, what fields you will need to fill in, etc.

QuestionAnswer
Form NameMetrolift Application
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesel metro lift application, metro lift eligibility, metrolift com, metrolift application form

Form Preview Example

1900 Main

P.O.Box 61429

Houston, TX 77208-1429

Client ID #

Date Entered

Processed by

Application for METROLift Service

Instructions: On pages 1 – 4 of this application, METROLift is asking for information about you and your ability to use METRO bus service. Please take the time to answer ALL questions carefully and completely. We cannot determine your eligibility for METROLift service without this information. A friend, guardian, caregiver, agency service representative or family member may help you complete your portion of the application, pages 1- 4. Accurate information is required about you, your medical impairment, and your functional capacity. Pages 5 - 6 must be completed and certified by a physician/certified health professional who is familiar with your impairment or condition.

If you have questions, please call METROLift Customer Service at 713-225-0119.

Have you ever applied for METROLift?

No

Yes

TO BE COMPLETED BY APPLICANT

Name of Applicant

Last/Apellido

First/Nombre

Middle/Inicial

Social Security Number (ONLY last 4 digits)

Nombre de solicitante

 

 

 

Numero del Seguro Social del Solicitante

 

 

 

 

(Los ultimos 4 numeros)

 

 

 

 

 

 

 

 

 

 

XXX - XX - __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address/Street / Dirección/Calle

 

Apartment

City/Ciudad

 

 

 

 

Zip Code/Codigo Postal

 

 

 

 

Numero de Apatamento

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth/Fecha de Nacimiento

 

Home Phone Number/En Casa Número de Teléfono

 

 

Other Phone/Otro Teléfono

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment Complex Name/Nombre

 

 

 

 

 

 

 

 

 

 

 

Gate Code/Codigo de Cochera

de Apartamentos

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address/Dirección de Envío

 

 

City/Ciudad

 

 

 

 

State/Estado

 

 

Zip Code/Codigo Postal

If different from home address/Si diferente de domicilio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Signature (required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Firma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

Date/Fecha

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Emergency Contact/Contacto de Emergencia

 

Relationship/Relación

Emergency Phone/Numero de Emergencia

METRO 0447-16

Page 1

I N DI V I DU AL AN D M OBI LI T Y I N FORM AT I ON

1.Please state your disability(s).

2.What assistive device(s) do you use when traveling? (Please check all that apply.)

Support Cane

Manual wheelchair

Trained service animal

Crutches

Powered wheelchair

Communications device

Walker

Power scooter

“White cane”

Leg brace(s)

Portable oxygen

None

Other (describe)

 

 

3.What is the nearest street intersection to your home? (Example: Polk & Wayside)

4.Can you walk or use your wheelchair or assistive device(s) from your home to that

intersection without assistance?

 

Yes

 

No

If “no,” please explain.

 

 

 

 

 

5.Can you find your way to a bus stop without getting lost? If "no," please explain.

Yes

No

6.

How long can you stand and wait for a bus?

 

 

 

 

15 minutes

10 minutes

5 minutes

Less than 5 minutes

7.

All buses have a "destination sign" in front, which shows the route name and number.

 

Can you read a bus destination sign?

 

Yes

No

 

Can you ask the driver where the bus is going?

Yes

No

 

Can you give or write a note to the driver?

 

Yes

No

 

Can you understand the driver's answer?

 

Yes

No

 

If "no" to any questions, please explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2

8. If you were on the bus, could you pay the fare by putting money in the fare box, or by tapping the

METRO Q Card on the Q box?

.

If “no” please explain

Yes

No

9. If you were on the bus, could you recognize the place where you wanted to get off the bus?

Yes No

If "no," please explain.

10.Please tell us about the times when you can use METRO’s local fixed-route bus service? (Example: if short distance to bus stop; take attendant; need to get somewhere.)

11.Have you ever received " orientation and mobility training "or " travel training?" Yes If " yes," please list any METRO bus routes on which you can travel:

No

12.Please tell us the reasons you feel you cannot use METRO’s local fixed-route bus service for some or all trips.

13.How do you currently travel (self, family, friends, bus, rail, METROLift, etc.)? Please explain.

14.Do you require someone to travel with you?

Yes

If "yes," please explain

 

No

15.Can you wait independently alone at your residence and places to which you travel?

Yes No

If "no," please explain.

Page 3

AGREEMENT AND AUTHORIZATION:

I state that the information I have provided is true and accurate.

I authorize the release of diagnostic and functional information as requested on pages 5 and 6 to METRO for the sole purpose of making a determination regarding my eligibility for paratransit service (METROLift) and understand that personal and medical information will be kept confidential.

I understand that intentionally providing false or misleading information or refusal to undergo an in-person interview assessment is grounds for denial of METROLift services.

If approved, I agree to follow the rules and guidelines established by METROLift and to promptly inform METROLift of any changes in my residence, phone number and, if applicable, my representative's name and phone number; and any significant change in my condition that would affect my level of mobility.

I understand that failure to follow proper procedures or cooperate with METROLift staff, demonstrating illegal or disruptive behavior or, if my condition at any time poses a direct threat to the health or safety of others, such situations may result in either suspension and/or termination of service.

Applicant’s Signature:

Date:

If someone other than the applicant is preparing this form, please provide the following information about the preparer:

Name: (please print) ________________________________________________

Day Phone: ______________________________ Relationship: ______________

Preparer’s Signature: ______________________ Date: ____________________

Page 4

Dear Physician or Healthcare Professional:

We need your assistance in determining eligibility for services provided by METROLift to persons with disabilities who are unable to use local bus transportation. We are seeking specific information as to what prevents the person from using METRORail and the METRO bus routes that provide transportation throughout the area. METRO buses are equipped with ramps, lifts, and kneeling features to assist boarding as well as automatic announcements of major stops to help riders know where they are along the route. The Americans with Disabilities Act of 1990, 49 CFR 37.121, Subpart F states– “..each public entity operating a fixed route system shall provide paratransit or other special service to individuals with disabilities that is comparable to the level of service provided to individuals without disabilities who use the fixed route system.” “By complementary, DOT means service for individuals with disabilities who cannot use the fixed route bus system.” The information requested of you in the following sections will be used to help determine the applicant’s METROLift eligibility. It is important that all questions be answered completely and accurately to the best of your knowledge and in accordance with your records. If the information is incomplete or unclear, we may need to contact you for clarification. Thank you for your cooperation.

1. Have you previously seen this patient?

Yes

No

2. Please rate (Excellent / Good / Fair / Poor / None / Don’t Know) the applicant in terms of:

a. Upper body strength

b. Lower body strength

c.Coordination

d.Balance

e.Self awareness

f.Independent judgment

g.Sense of direction

h.Ability to understand and follow instructions

i.Verbal communication

j.Written communication

k.Stamina and endurance

Excellent Good Fair Poor None Don’t Know

3. In your opinion, can the applicant travel independently from his/her house to the sidewalk?

Yes

No

Sometimes

If "no" or "sometimes," please explain.

4. Can the applicant walk up and down two steps?

Yes

No

Sometimes

5.Assuming the use of a mobility aid, if applicable, and with no major barriers in his/her path, how far can the applicant independently travel without assistance?

less than 1/4 mile

1/4 mile

1/2 mile

3/4 mile

more than 3/4 mile

Page 5

6. Does the applicant’s disability require him/her to travel with another person who provides personal

assistance?

Yes

No

Sometimes

7.Please provide medical diagnoses in layman’s terms to describe the applicant’s primary impairments or disabling conditions.

8.We are seeking specific information as to what prevents your patient from accessing the local bus and rail system.

9.

Is the condition

Permanent or

Temporary (months)

 

10.

If visually impaired, what is the applicant's best corrected acuity?

 

(Snellen)? (R)

 

 

(L)

 

 

 

 

 

 

 

 

Field Restriction: (R)

 

 

(L)

 

 

 

Date of Testing:

 

 

11.

If cognitively impaired, what is the applicant’s cognitive age, and IQ level?

12.

Is the applicant a wheelchair user?

Yes

13.

Does the applicant use other mobility aids?

 

No

Yes

If yes, how often

No If yes, please describe.

PHYSICIAN OR HEALTH CARE PROFESSIONAL’S CERTIFICATION :

I certify that the information I have provided herein is a fair representation of this applicant’s medical impairment or condition and is accurate to the best of my knowledge. I understand that the information provided herein will be used for the sole purpose of determining the applicant’s eligibility for paratransit services. I also agree that METROLift may contact me for clarification of any information I have provided and that I will reply in good faith.

Physician’s/Health Professional’s Full Name

Institution/Facility/Agency Name

Street Address

 

 

 

 

 

 

 

 

Suite #

 

 

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

 

Medical/Social Worker’s License Number

 

 

Telephone #

 

 

 

Fax #

 

 

 

Physician’s/Health Professional’s Signature

 

 

 

 

 

 

 

Date

 

 

***Note: Additional signature of physician/healthcare professional on his/her letterhead or prescription verifying completion of application is required.

Page 6