Palm Tran Connection – Fill Out and Use This PDF

Paratransit Eligibility Application

www.palmtran.org

Completed applications accepted via mail / fax / email or in person at:

Palm Tran CONNECTION

Community Transportation Coordinator

50 South Military Trail, Suite 101

West Palm Beach, Florida 33415

Monday – Friday

8am – 4:30pm

561-649-9838 option 4

1-877-870-9849 toll-free outside local calling area

Eligibility Fax: 561-656-7156

Email: connpalmeligibility@pbcgov.org

INSTRUCTIONS FOR COMPLETING THIS APPLICATION: Please complete the appropriate Part(s) of this application depending upon which programs you are eligible for. If you do not complete the appropriate Part(s), we will not consider your eligibility for that program. If you complete two or more Part(s), we will consider your eligibility for multiple programs.

Regardless of program preference, Part 1 must be completed in its entirety.

Part 1:General Rider Information

Part 2:Applicant Signature Page

Part 3:Verification of Income Transportation Disadvantaged Program OR Bus Pass Program

Part 4:Verification of Disability Americans with Disabilities Program

Per the Americans with Disabilities Act (ADA), complementary Paratransit is not intended to be a comprehensive system of transportation for individuals with disabilities.

The completed application will be reviewed within 21 days after it is received by Palm Tran CONNECTION to determine the applicant’s eligibility for service. If a decision is not made within 21 days of receiving a completed application, the applicant shall be treated as eligible and shall be provided service unless PTC denies the application. Applicants who are denied eligibility have the right to appeal that decision. Please contact the eligibility department if you have further questions.

The information in this application will be used by Palm Tran CONNECTION for the provision of transportation services. Information will be available to other transit providers as necessary for appropriate transportation services only. The information will not be provided to any other person or agency. This document is available in an alternative format upon request.

APPLICATIONS ARE PROCESSED IN THE ORDER THEY ARE RECEIVED.

PROCESSING APPLICATIONS MAY TAKE FROM 7 TO 21 DAYS OF RECEIPT TO COMPLETE.

Revised April 2019

Paratransit Eligibility Process

In compliance with the Americans with Disabilities Act of 1990 (ADA), Palm Tran offers paratransit service for persons with physical, cognitive, visual or other disabilities which functionally prevent them from using our fixed-route bus system permanently, temporarily or under certain conditions. Disability alone does not consent one’s eligibility for ADA paratransit service. The decision is based solely on the applicant's functional ability to use Palm Tran fixed-route service. All Palm Tran buses are fully assessable and compliant with the requirements of the ADA. The unavailability of fixed-route service, difficulties using fixed route or long travel times do not constitute eligibility for paratransit service.

PALM TRAN CONNECTION APPLICATION PROCESS

All applicants seeking ADA Paratransit Service must undergo an eligibility determining process. The application process includes, but not limited to:

•A personal assessment or in-person interview may be required to determine applicant’s disability.

•A medical verification of the disability completed and signed by a licensed physician.

Functional inability to use public transportation includes the Americans with Disabilities Act (ADA) Categories 1, 2 and 3 as described in this application.

AMERICANS WITH DISABILITIES ACT (ADA) CATEGORIES:

Check the categories of eligibility that you recommend should apply.

1.[ ] The individual is unable, as a result of a physical or mental impairment (including a vision impairment), and without the assistance of another individual, (except the operator of a wheelchair lift or other boarding device), to board, ride, or disembark from an accessible bus or rail vehicle.

2.[ ] The individual needs the assistance of a wheelchair lift or other boarding assistance device and is able, with such assistance, to board, ride, and disembark from accessible transit vehicles. (The individual would be eligible if an accessible vehicle is not available.)

3.[ ] The individual has a specific impairment-related condition which prevents the individual from traveling to or from: Palm Tran fixed route bus stop.

4.[ ] Check here, if none of these categories apply.

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Part 1

General Rider Information

Please Print Pick Up Information

Last Name: ______________________________ First Name: __________________________ MI: _____

Street Address: _______________________________________ Apt#:_________ Bldg#:_____________

Email address:_______________________________________________

Mailing Address if different

Street Address: _______________________________________ Apt#:_________ Bldg#:_____________

A.Please indicate below if you use any of the following mobility aids or equipment (check all that apply)

○Other (please specify)_______________________________________________________

○I don’t use any of the above mobility aids or equipment

Note: We may not be able to accommodate you if your wheelchair/scooter is longer than 54 inches or wider than 34 inches or if your total weight when occupying your wheelchair exceeds 600 pounds.

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Part 1 (Continued)

B.Do you require the assistance of a Personal Care Attendant (PCA) (someone who must travel with you to assist you with daily life functions)?

A PCA is not provided by Palm Tran Connection. Personal Care Attendant (PCA) is someone who is provided by you,

to help with your personal needs, including traveling. A PCA may always travel with an eligible client.

*Please note that we may require you to travel with a PCA if your condition or disability is severe.

C.Do you need to have information given to you in an alternative format? If yes, please indicate: ○Large print ○Other:___________________________________________

Part 2

Applicant Certification – Signature

I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility for the provision of transportation services. Your information will also be available to other transit providers as necessary for appropriate transportation services. The information will not be provided to any other person or agency. I certify that, to the best of my knowledge, the information in this evaluation form is true and correct. Any person who knowingly makes a false or misleading statement in an application may be denied eligibility for Paratransit services.

Applicant’s Signature: _______________________________ Date: ______________________

If applicant is unable to sign due to disability, a Power of Attorney or Health Care Proxy document is required.

If someone assisted you in completing this form, please provide contact information:

Name: _______________________________ Phone: _____________________________________

In Case of an Evacuation:

In the event of a mandatory evacuation order issued by Palm Beach County Emergency Management due to a Hurricane or Flood, would you need transportation to a shelter?

○Yes ○No

To register for the Special Care Unit, please contact the Palm Beach County Emergency Operations Center at (561) 712-6400.

Be advised Nursing Homes, Assisted Living and Rehabilitation Facilities are responsible for the transportation of their resident to a shelter due to a mandatory evacuation order issued by Palm Beach County Emergency Management.

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Part 3 Transportation Disadvantaged (TD) Program – Does not require a disability.

Application Certification – Verification of Income

A.To apply for the Transportation Disadvantaged (TD) Program, please complete the following:

Total monthly income $____________________

Please attach proof of your total income, before tax, including wages, tips, any Social Security income, Pension and other.

Do you have a physical or mental impairment that substantially limits one or more of the major life

○Mobility Impairment (Stroke, brain spinal nerve trauma)

○Neurological Disability (MS, MD, Cerebral Palsy, Epilepsy, Alzheimer’s, Parkinson’s, other) ○Visual Disability (Macular Degeneration, visually impaired, legally blind)

○Uncontrolled Fatigue (Chemo/Radiation, Dialysis)

○Cognitive or Sensory Impairment (Autism, down syndrome, dementia, developmental, other) ○Impairment Related (Hearing impaired, Cardiac/COPD, respiratory, arthritis, neuropathy)

*Question is required, but not used in determining your eligibility

Part 4

Applicant Certification – Verification of Disability

A. To apply for the American’s With Disability Act Program, please complete the following:

Please indicate below the reasons why you are seeking Door to Door eligibility (check all that apply)

To qualify for Palm Tran CONNECTION a person must be UNABLE to use Palm Tran fixed-route buses due to a physical or mental impairment related condition

○Because of my disability, I can never use the Palm Tran fixed-route bus service

○I can use Palm Tran fixed-route buses sometimes, but only if they are equipped with wheelchair lifts

○I can use Palm Tran fixed-routes buses to go some places, but in other places I cannot get to or from the bus stops

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Part 4 (Continued)

B.What type(s) of disabilities prevent you from using Palm Tran buses? (check all that apply):

○Mobility Impairment (Stroke, brain spinal nerve trauma)

○Neurological Disability (MS, MD, Cerebral Palsy, Epilepsy, Alzheimer’s, Parkinson’s, other) ○Visual Disability (Macular Degeneration, visually impaired, legally blind)

○Uncontrolled Fatigue (Chemo/Radiation, Dialysis)

○Cognitive or Sensory Impairment (Autism, down syndrome, dementia, developmental, other) ○Impairment Related (Hearing impaired, Cardiac/COPD, respiratory, arthritis, neuropathy)

Please describe your disability in more detail: ______________________________________

______________________________________________________________________________________

C. Is the disability described above temporary or permanent?

○Temporary, I expect it to last for another __________ months

○Permanent ○I don’t know

D. Have you ever used Palm Tran fixed-route bus service?

○Yes, I use the following bus routes __________________________________________

○No

E. When are you UNABLE to use the Palm Tran fixed-route bus? (Please indicate below – check all that apply to you)

○I can use Palm Tran regular bus service for some trips, but other times there are barriers that prevent me from using the bus.

○I have difficulty understanding, become disoriented easily and/or remembering all of the things I would have to do to use the bus.

○I can only get to and from bus stops if the distance is not too great and there are curb cuts and sidewalks on the route.

○I can only wait at Palm Tran bus stops if there is a bench or shelter and/or I cannot cross busy streets and intersections.

○The severity of my disability can change from day to day. I can ride the bus only when I am feeling good.

○I have difficulty or cannot climb stairs and can only board a Palm Tran bus if is has a lift or ramp.

○I have a health condition and cannot ride the bus if the walk is too far or if the weather is

Part 4 Continued

F. Would any of the following help you to use the fixed-route buses?

○Route and schedule information ○Bus stops closer to your home ○A communication aid

○Bus stops closer to where I live and where I need to go ○None of these would help

○Travel Training (how to ride the bus)

G.Can you ask for and follow written or verbal instructions to use Palm Tran fixed-route buses?

○Yes ○No○Sometimes

If you choose either NO or sometimes, please check all that apply

H.Without the help of someone else, are you ABLE to do the following? (check all that apply)

○Walk up and down three steps if there are handrails on both sides ○Use a telephone to get information

○Ask for and follow written or oral instructions ○Cross the street if there are curb cuts

○Get on and off a Palm Tran bus if it has a wheelchair lift

○Wait 30 minutes at a bus stop that does not have a bench or shelter

○Easily hear the bus drivers’ voices when they announce bus routes while you are standing outside or inside the bus

○Step on and off a sidewalk that does not have a curb cut ○Cross streets and intersections

○Hear traffic well enough to safely cross streets

○See well enough to walk to a bus stop if someone shows you the way once

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Part 4 Continued

I.Using a mobility aid (wheelchair, etc.) or on your own, how far can you walk or travel?

○Cannot walk outside my house/apartment

○I can get to the curb in front of my house/apartment ○I can walk or use wheelchair up to 3 blocks

○I can walk or use wheelchair up to 6 blocks ○I can walk or use wheelchair up to 9 blocks

J.Can you WAIT up to 30 minutes for the Palm Tran fixed-route bus at a bus stop?

○Yes

○Yes, only if the stop has a bench and shelter ○Yes, but I do not like to wait that long

○No, explain:____________________________________________________________________________

__________________________________________________________________________________________

If applying for the Americans with Disabilities Program or the Transportation Disadvantaged

Program, please have your PHYSICIAN complete the attached

(MEDICAL VERFICATION FORM)

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MEDICAL VERIFICATION, CONTINUED

(TO BE COMPLETED BY A LICENSED PHYSICIAN)

7.COGNITIVE OR SENSORY IMPAIRMENT:

8.IMPAIRMENT RELATED CONDITION:

9.DESCRIBE IN DETAIL THE APPLICANT’S PRIMARY DISABILITY: (BE SPECIFIC):

10.IS THIS DISABILITY:

Permanent

Temporary: This is to certify that the applicant stated within is a person with a temporary disability (six months or less) that limits or impairs his/her ability to walk or is temporarily sight impaired.

Is this disability controlled by medication?  Yes  No

Explain:

________________________________________________________________________________________________

Please attach any pertinent medical documentation (Test Results, Notes, Reports, etc.) that would help to explain the diagnosis or limitations on the applicant’s ability to utilize Palm Tran’s mass transit system.

WARNING: Any person who knowingly makes a false or misleading statement in an application or certification may be denied eligibility to Paratransit services.