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V.6-6-12

APPLICATION FOR PARTICIPATIONIN THE MARYLAND TRANSIT

ADMINISTRATIONMOBILITY / PARATRANSIT PROGRAM

This information will be used to determine eligibility for MTA’s Mobility program and may be shared with other transit providers or State entities. The information will be kept confidential in accordance with state law. The failure to provide the requested information may result in the denial of eligibility. Providing false information on this application may constitute a crime punishable under law.

Directions

Fill out Part A of the application. Be sure to answer all questions as completely and specifically as you can. This information will be used to determine your eligibility for MTA Mobility services.

Part B of this application should be filled out by a healthcare professional. The healthcare professional who knows the most about the disability that most prevents you from using the public transit systems (bus, light rail, metro), should complete the form. The healthcare professional must sign Part B of the form and include his or her license number and type of license.

Once you and your healthcare professional have completed the application, MTA requires an in-person interview. To obtain an appointment, call MTA Mobility at 410-764-8181. Follow the telephone prompt menu and select Certification. The MTA Certification Office is open from 8:00 a.m. to 4:30 p.m., Monday through Friday, excluding State holidays. Once you reach an agent, an appointment for your in-person interview will be scheduled.

This in-person interview is a required part of the application. In-person interviews are held at the Mobility Certification Office at 4201 Patterson Ave, 2nd Floor, Baltimore, Maryland 21215. You may be asked to participate in a functional assessment to help determine your abilities. Functional assessments are performed by

independent, qualified medical personnel under contract to the MTA. If you are asked to do a functional assessment, it may be conducted at the facility of MTA’s contractor or at the Mobility Certification Office.

Transportation will be provided for the assessment.

You must bring your completed application with you to the interview. MTA does not accept missing, incomplete or faxed applications, and will not conduct the interview if the application is not complete. If you bring in an incomplete application, a new appointment will need to be made and the determination of your eligibility and your service will be delayed.

After the interview and/or functional assessment, MTA will determine your eligibility. If you are deemed eligible, MTA will provide you with a card as proof of your eligibility for Mobility services. The card may be given to you at the time of the interview or mailed to you after the interview.

Taxi Access II is a separate program from MTA Mobility that offers Mobility customers additional transportation options. Extensions of eligibility for Taxi Access II are not available for any reason. If your Taxi Access II card has expired, you must renew your Mobility card and wait for your new Taxi Access II card to be mailed to you.

If you are NOT a current Taxi Access II customer, but you do wish to have Taxi Access II services, more information will be available to you at the interview.

APPLICATION 1

V.6-6-12

PART A: APPLICANT INFORMATION (PLEASE PRINT)

Date__________________________

MTA Mobility Services. Please check one:

Re-certification Application

Mobility ID# ______________________________First Application

Taxi Access II. Are you interested in Taxi Access II service?

Yes-renewing Taxi Access II Yes –new Taxi Access II

No-not interested in taxi

The MTA Taxi Access program is a premium service that is not part of the complementary paratransit service provided by MTA pursuant to federal law. The Taxi Access program is a transportation option available to Mobility eligible customers. Participation in Taxi Access does not affect eligibility for MTA Mobility.

Last Name ___________________________First Name___________________________MI _______________

Street Address ____________________________________________________________Apt # _____________

City ________________________________State________________________________Zip Code __________

Home Phone Number () ____________________________Cell Phone Number () ________________________

Date of Birth _______________________________Male ___________________Female__________________

Email Address for correspondence (Optional): ____________________________________________________

Emergency Contact Name: ____________________________________________________________________

Emergency Contact Phone Number:() _____________________________Relationship ___________________

Name of subdivision or apartment complex: ______________________________________________________

Nearest major intersecting street: _______________________________________________________________

Nearest cross street to your residence: ___________________________________________________________

List the Medical Names of Your Disabilities or Medical Conditions

Is the ConditionPermanent?

Duration ofCondition

Beginning Date	Ending
Date

APPLICATION 2

V.6-6-12

1.Please describe how your physical or mental condition(s) limit your ability to access the bus stops or stations; ride the bus, metro/subway, light rail, or train; or transfer to another regular bus, metro/subway, light rail, or train. Please be specific.

_______________________________________________________________________________________

2.Do you have a Cognitive Disability? (Have you ever been diagnosed with Traumatic/ Non-Traumatic Brain

Injury, Developmental Disability, Borderline Intelligence, Down’s syndrome, Autism, etc.?)

Yes

If yes, please state the disability and explain how it affects you.

_______________________________________________________________________________________

3. Do you experience any of the following? Please check all that apply:

Panic Attacks		Easily Wander Off
Anxiety		Seizures
Hallucinations		Visual Impairment
Delusions		Short Term Memory Loss
Paranoia		Long Term Memory Loss
Confusion		Cannot Identify Pictures
Hear Voices		Cannot Read or Write
Easily Taken Advantage of by Others		Difficulty Understanding Written or Verbal
		Instructions

4. If you experience Seizures, please check all that apply and answer the following questions:

__________________

4c. How often do your seizures occur?________________________________________________________

When was your most recent seizure? _________________________________________________________

4d. Are you currently taking medication to control seizures? Yes

5.Are you currently taking prescribed medications that will, by themselves, affect your ability to ride the buses and/or trains? Yes No

Please explain ___________________________________________________________________________

APPLICATION 3

V.6-6-12
6. Do you have a Visual Impairment (to include Blindness)? Yes	No
If yes, please check all that apply:
I wear contacts or glasses.

I can recognize my stop if announcements are made.

I am legally blind and cannot distinguish my appropriate stop, disembark, and navigate the route to my destination. I do not use a guide dog or other service animal, or any assistive device.

I use a guide dog or other service animal, but I need paratransit to get to/from destinations that I cannot safely travel to on the route.

I can easily hear and recognize environmental sounds that help me to determine the traffic flow patterns.

I cannot easily hear environmental sounds that help me to determine traffic flow. I cannot always get out of the roadway before the traffic signal changes.

I require a sighted guide to assist me with the following tasks: _________________________________

7. Do you have a Mental/Psychological Disability? (Have you ever been diagnosed with Bipolar Disorder, Schizophrenia, Anxiety Disorder, Paranoia, etc.?)Yes No If yes, please state the disability and explain how it affects you.

_______________________________________________________________________________________

8.Are there any other physical or mental disabilities that affect your FUNCTIONAL ABILITY to ride the regular fixed route, accessible bus and transit service? (Example: difficulty with getting to the bus, waiting

at the stop for the correct bus, boarding thebus, knowing when you get to your stop, and notifying the driver

that you need to getoff.) Yes

If yes, please explain.

_______________________________________________________________________________________

9.Can you wait 20 minutes at an MTA bus stop or station that DOES NOT have seats? Yes No If no, please explain.

_______________________________________________________________________________________

10.Can you wait 20 minutes at an MTA bus stop or station that DOES have seats and a shelter?

Yes

If no, please explain.

_______________________________________________________________________________________


11.	Can you wait 20 minutes at a bus stop or station unassisted? Yes							No	If no, please explain.
	______________________________________________________________________________________
	______________________________________________________________________________________
	______________________________________________________________________________________
12.	How far can you walk without the assistance of another person? Please check.
		Less than one block		3-4 blocks		Over 6 blocks
			1-2 blocks		5-6 blocks		I don’t know

APPLICATION 4

V.6-6-12

13. Do you require a ramp or lift in order to board/exit the bus? Yes


14.	Do you use a mobility device to travel? Yes						No	Please check all that apply.
		White Cane				Orthopedic Cane (three or four prong base)
			Standard Cane			Walker		Braces	Crutches
			Manual Wheelchair			Motorized Wheelchair		Scooter
			Respirator/Oxygen			Service/Guide Animal Describe:_________________________________
15.	Do you require a personal care assistant (PCA) to travel with you to provide transportation assistance?
	Yes			No	If yes, please explain the specific assistance you require.

_______________________________________________________________________________________

16.	How do you travel now? Please check all that apply.
		Wheelchair/scooter		Walk			Drive myself
			Passenger in someone else’s car		Other van service
			Regular fixed route bus, metro, light rail		Currently have no means of travel
			Mobility paratransit

17.	Have you ever ridden a regular fixed route, accessible bus? Yes					No

If yes, when was the last time you rode a, regular fixed route accessible bus or transit service?

_______________________________________________________________________________________

18. Have you stopped using the regular fixed route, accessible bus or transit service? Yes

If yes, please explain______________________________________________________________________

19. Do you feel that you could ride the regular fixed route, accessible bus or transit service if the paratransit van

could get you to/from an accessible bus stop? Yes

If no, please explain.

_______________________________________________________________________________________

20. Please check all that apply to you:

I am able to board, ride, and exit a regular fixed route, accessible bus.

I can cross the street.

I can step on and off the sidewalk.

I can stand on a moving bus, holding the handrail, if no seat is available.

I can use a telephone to get bus schedule information.

I can find my way to the bus stop after being shown where it is based.

I can transfer to another bus or train after being shown where it is based. I can hear and understand the automatic announcement system on the bus.

I need assistance understanding and navigating the fixed route system.

I do not have the stamina to travel long distances.

21. Is there anything else you wish to tell us about your ability to travel outside your home?

_______________________________________________________________________________________

I hereby certify, under the penalties of perjury, that the information submitted is true and correct. I understand

APPLICATION 5

V.6-6-12

that providing any false information on this application may constitute a crime punishable under the law. I understand that the MTA will rely upon this information in making a determination as to my eligibility for participation in this program.

I understand that I am required to participate in an in-person interview as part of this application, and that I may also be required to participate in a functional assessment. I further authorize the release of any personal or medical information to appropriate parties that is necessary in the determination of my eligibility for Mobility / Paratransit Services.

Applicant Signature: ______________________________________________ Date: _____________________

If a person other than the applicant has completed this form, please check one:

I certify that the information provided in this application is true and correct based upon the information given to me by the applicant. I helped fill out the form.

I certify that the information provided in this

application is true and correct based upon my own knowledge of the applicant’s health condition or

disability.

Print Name: ________________________________________________________________________________

Signature: _________________________________________________________________________________

Relationship to Applicant: ____________________________________________________________________

Telephone:__________________________________ (day)_________________________________ (evening)

PLEASE READ THIS APPLICATION AGAIN. ANSWER AND EXPLAIN EVERY QUESTION THAT

APPLIES TO YOUR CONDITION TO THE BEST OF YOUR ABILITY AND INCLUDE

ADDITIONAL INFORMATION IF NEEDED.

FAILURE TO DO SO WILL DELAY A DETERMINATION OF ELIGIBILITY.

WE WILL PROCESS YOUR APPLICATION ONLY WHEN IT IS COMPLETE.

APPLICATION 6

V.6-6-12

PART B: LICENSED PROFESSIONAL VERIFICATION

Dear Licensed Professional:

The Americans with Disabilities Act (ADA) of 1990 is a civil rights bill prohibiting discrimination against people with disabilities. In accordance with the Act, MTA offers an origin-to-destination bus service for those who cannot use the regular fixed-route buses.

Passengers must be certified eligible in order to use the origin-to-destination bus service. Applicants may be found eligible for this bus service for some trip requests but not for all trips they request. Eligibility is based upon a functional inability to use the regular transit service, due to a disability or disabling medical condition.

All regular fixed-route buses are equipped with a ramp or lift for people who use a wheelchair or cannot climb stairs.

To qualify for the MTA Mobility / Paratransit Program, an individual must have a disability and be unable, as a result of a physical or mental impairment, to board, ride or exit from any accessible MTA vehicle. A disability

that prevents the person from navigating the system also qualifies. A disability that prevents a person from traveling to/from bus stops or subway and rail stations also qualifies. The fact that the applicant’s medical

condition makes using the public transit system more difficult is not a basis for eligibility for the program. Applicants may be referred to a medical provider for a functional assessment as part of the certification process.

The safety-net public-transit system, provided by the ADA, is origin-to-destination paratransit service, locally called Mobility. Income is not a factor in determining an applicant’s Mobility / Paratransit eligibility. This is a

shared-ride service that provides trips to/from addresses that are within ¾ of MTA fixed-route services (local bus, metro subway, and light rail). It requires reservations ahead of time. Direct trips are unusual. The current fare is $1.85 per trip (each way). Rides take about the same amount of time as do rides on the fixed-route services.

The information you provide, along with the applicant’s information, and information from other sources, will enable us to make an appropriate determination. All information will be kept confidential.

Thank you for your assistance.

MTA Mobility Certification

APPLICATION 7

V.6-6-12

PART B. THE FOLLOWING SECTION IS TO BE COMPLETED BY THE APPLICANT’S PHYSICIAN OR OTHER HEALTHCARE PROFESSIONAL:

_____________________________________________________________________________________________

Applicant’s Name (printed)

_____________________________________________________________________________________________

Date Of Birth

The customer must BRING this form, completed and signed, with him/her to the appointment at MTA Mobility Certification. You MAY put it in a sealed envelope, with your official logo & return address, at your discretion. You do not need to fax or mail this form to MTA Mobility.

PART B: INSTRUCTIONS

In deciding whether the applicant is eligible for MTA’s Mobility / Paratransit Program, the MTA will consider input from the applicant’s healthcare professional, in-person interview, and the information provided on the

application.

Please focus your response on the functional ability of the applicant. If a person is Mobility/ Paratransit eligible for some trips but not others, please specify any such limitations.

Please print applicant’s name and answer all questions completely using your professional opinion. The healthcare provider must fill out this section, not the applicant.

1.When this person uses the public transit system, will he/she be successful at using the REGULAR fixed-route public transit system, meaning MTA local bus, metro subway, or light rail, independently?

YES-can use fixed-route

SOMETIMESNO-prevented from using fixed-route

2. Why would this person be prevented from using regular, fixed-route public transit services?

Chemotherapy/Radiation		Impaired Vision

Chronic Pain		Intellectual Functioning

Dialysis Treatment		Limited Standing

Fatigue/Exhaustion		Limited Walking

Impaired Gait		Recent Seizures

Impaired Memory		Uses a Wheelchair

OTHER:

3.If you believe that the person is unable to ride MTA Local Buses, Metro Subway, or Light Rail due to the medical condition, how long do you expect the limitation to last?

3 months

6 months

9 months

1 year

3 years

4.Please specify your patient’s disabilities (formal diagnosis, including DSM and ICD codes). Without

this information, your client will NOT be found eligible to ride on paratransit. Please list all disabilities, diagnoses and/or injuries that affect this person’s ability to use public transit.

_______________________________________________________________________________________

APPLICATION 8

V.6-6-12

5.5a. Can the person, with the assistance of a working wheelchair lift or other boarding assistance

device, board, ride, and exit from an MTA Mobility / Paratransit cutaway bus?

YesNo

5b. Can he/she board, ride, and exit from an MTA Mobility / Paratransit sedan?

Yes

Note: MTA is unable to provide sedan-only service to any customer.

5c. Can he/she, with the assistance of an extending ramp, board, ride, and exit from an SUV-type vehicle?

Yes

6.Does the person’s medical condition/disability make it necessary that a Personal Care Attendant (PCA) accompany them when travelling with Mobility? A PCA is a person designated by the MTA Mobility client to help meet his or her personal needs while traveling or at their destination.

Yes No

If yes, please describe why. Or, what tasks will the PCA assist the client with?:

_______________________________________________________________________________________

7.How long has this client been your patient? Or, how long have you known this person? ______________

I certify that the information I have submitted is my true and accurate medical opinion.

__________________________________________________________________________________________

Printed name of physician / healthcare professional

__________________________________________________________________________________________

Signature of physician / healthcare professionalDate Signed

Type of Medical license, professional certification, or degree held: ____________________________________

License Number:____________________________________________________________________________

Address ___________________________________________________________________________________

City ______________________________________________State _________________Zip _______________

Telephone Number __________________________________Fax number______________________________

Applicants who do not qualify for Mobility / Paratransit service may be eligible for

MTA Reduced Fare status on regular fixed-route services (Local Bus, Metro Subway, Light Rail).

Please call 410-767-3441 for more information on the Reduced Fare program.

CALL MTA MOBILITY at 410-764-8181 when your form is completed.

Ask to set up an appointment. Please do not mail or fax this application - bring it with you.

For more information about Mobility, call 410-764-8181 or Maryland Relay Service at 711.

This application is available in alternate format upon request

###

APPLICATION 9

Question	Answer
Form Name	Mta Online Form Side
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	mobility forms, maryland mobility application, mta disability application, mta mobility application pdf

4a. Which type of seizures do you have?

Petit Mal/absence

Temporal Lobe

4b. When having a seizure, I: (Please check all that apply)

Am Difficult to Arouse

Fall Asleep

Need Immediate Medical Attention

Stare Blankly into Space