The Potomac and Rappahannock Transportation Commission (PRTC) offers a beacon of hope for individuals who face challenges in accessing non-emergency medical transportation through their Wheels-to-Wellness program. Intuitively designed, the application process is split into two crucial parts, ensuring a comprehensive assessment of an applicant's needs and circumstances. Part I of the form requires detailed personal information from all applicants, alongside proof of residence, thus laying a foundation for eligibility based on several criteria including age, disability, low income, or lack of Medicaid coverage for non-emergency transportation. The inclusion of a section for transportation accommodations underlines the program's commitment to inclusivity, catering to individuals with diverse mobility requirements. Part II deepens this assessment by involving a medical certifier who confirms the applicant's disability status, further validating the need for specialized transportation services. Applicants are reminded of the importance of accuracy in their submissions, with the potential for review, verification, and even financial repercussions if discrepancies are found. This form not only serves as a gateway to much-needed transportation assistance but also as a testament to PRTC's thorough and thoughtful approach in addressing the mobility needs of the community it serves, all supported through a grant from the Potomac Health Foundation.
| Question | Answer |
|---|---|
| Form Name | Prtc Online Application Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | tripura prtc online no No Download Needed needed, prtc bus pass online apply, prtc from fill up, prtc online apply |
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A
PART I to be completed by all applicants.
PART II to be completed and signed by a medical certifier, if applying on the basis of a disability.
Completed form should be mailed to the Potomac and Rappahannock Transportation Commission (PRTC), faxed to (703)
Incomplete forms may cause processing delays.
PART I
Name___________________________________________________________________________
Address_________________________________________________________________________
City___________________________________ Zip Code: (please circle)
Proof of residence must accompany this application. Please refer to page 3 for acceptable documents.
20112 22025 22026
22125 22134 22172
22191 22192 22193
Telephone: Day (_____)_______________________ Evening (_____)_______________________
Male __________ Female __________ |
Date of Birth_______________________________ |
Social Security number (last four numbers only):
Why I Believe I Qualify for the
[] I am NOT eligible for
[] I am 80 years or older. (Attach a photocopy of a
[] I have a disability as defined by the Americans with Disabilities Act. (Must have a certifier complete Part II)
[] I live in a low income household.
Combined household income: $_______________ Number of persons in the household: ___________
(Combined household income of not more than 1.9 times the federal poverty level. See page 3 for information.)
Transportation Accommodations I Require:
[ |
] |
Wheelchair |
[ |
] |
Walker [ ] Service Animal (If other than dog, specify_________________) |
[ |
] |
Companion |
[ |
] |
Other, please explain:______________________________________________ |
I, ________________________________ (print) _________________________________ (signature), do certify that the
information provided herein is true and accurate to the best of my knowledge. I understand my application and eligibility criteria are subject to review and verification, and misrepresentation of any information may result in suspension or termination of my program enrollment and transportation assistance. I also understand that I may be required to reimburse PRTC for any monies afforded me as a result of providing inaccurate information or misuse of the electronic purchasing card issued to me under the program rules. I understand PRTC may conduct random and periodic income eligibility checks of participants enrolled in
Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703)
Page 1 of 4
Part II
To be completed by a physician or any one of the following state or nationally certified professionals: Physical Therapist, Occupational Therapist, Rehabilitation Counselor, Registered Nurse, or Social Worker.
Eligibility Criteria: Please check the eligibility criterion that pertains to the applicant.
[] Is required to use a wheelchair
[] Has an impairment that prohibits standing alone for ten (10) minutes or more and requires the use of a crutch, cane, brace, walker, or other assistance.
[] Cannot climb a flight of three (3) steps with an eight (8) inch rise, and cannot walk one hundred yards on a level surface of grade without pause.
[] Is legally blind . The definition of legal blindness is “central visual acuity of 20/200 or less in both eyes with best correction or visual field restriction of 20 degrees or less.
[] Has a diagnosis of a developmental or an intellectual disability, head injury, Alzheimer’s Disease or a related disorder, and has a cognitive impairment (inability to follow verbal, written, or pictorial directions) which causes disorientation, confusion, or demonstrates problematic stimulation when in an environment associated with crowds and / or noise.
[] Deaf or hearing impaired. (This guideline must be certified by either a licensed audiologist or a licensed otolaryngologist who is relying upon an audiogram for diagnosis): An individual whose hearing loss is 70 dba or greater in the 500, 1000, 2000 KHz ranges in both ears, regardless of the use of hearing aids.
Is the disability permanent? _____ Is the disability temporary? ______
If temporary, for how long (in months)? ________________________________
Do any of the following pertain to the applicant?
|
|
Yes |
No |
1. |
Has a medical condition that prevents him/her from using a seat belt. |
____ |
____ |
2. |
Must travel with an escort or companion. |
____ |
____ |
|
(If “Yes”, applicant will be required to travel with an escort at all times.) |
|
|
3. |
Requires the assistance of a service animal in order to travel. |
____ |
____ |
This information reflects my professional judgment that the applicant is eligible according to the criteria
established here. |
|
Certifier’s Name: |
________________________________________________________________________ |
Profession: |
________________________________________________________________________ |
Address: |
________________________________________________________________________ |
Telephone Number: |
___________________ Registry/State Certification Number: ______________________ |
Certifier’s Signature: |
__________________________________________________ Date:_________________ |
To be completed by PRTC
Authorized by:___________________________________________________ Date: ____________________
Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703)
Page 2 of 4
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Proof of Residency:
To provide proof of residency, the document must show your name and address of your current residence as it appears on this application. You must give a street address. A post office box or business address is not acceptable.
Homeless individuals may be able to substitute proof of residency for proof of services received if they are receiving assistance from a social service agency or a
Examples of acceptable documents are:
Utility bill, not more than two months old, issued to applicant (examples include gas, electric, sewer, water, cable or phone bill). Cellular phone and pager bills are not accepted
Payroll check stub issued by an employer within the last two months
U.S. Internal Revenue Service tax reporting
U.S. or Virginia income tax return from the previous year
Original monthly bank statement not more than two months old issued by a bank
Annual Social Security Statement for the current or preceding calendar year
Current automobile or life insurance bill (cards or policies are not accepted)
Certified copy of school records/transcript from a school in which applicant is currently enrolled, issued by a school accredited by a U.S. state, jurisdiction or territory OR a Virginia Department of Education state, jurisdiction or territory OR a Virginia Department of Education Certificate of Enrollment form (a report card is not accepted)
Virginia Voter Registration Card
Virginia driver’s license, learner’s permit or DMV photo ID card displaying the applicant’s current Virginia address
Certificate of Enrollment form (a report card is not accepted)
Current homeowners insurance policy or bill
Cancelled check (not more than two months old) with both name and address imprinted
Deed, mortgage, monthly mortgage statement or residential rental/lease agreement
U.S. Postal Service change of address confirmation form or postmarked U.S. mail with forwarding address label
Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703)
Page 3 of 4
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The Federal Poverty Guidelines
How the Census Bureau Measures Poverty
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Following the Office of Management and Budget's (OMB) Statistical Policy Directive 14, the Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty. If a family's total income is less than the family's threshold, then that family and every individual in it is considered in poverty. The official poverty thresholds do not vary geographically, but they are updated for inflation using Consumer Price Index
Source: U. S. Census Bureau, Small Area Income & Poverty Estimates for states and counties; updated every year. http://www.census.gov/did/www/saipe/ .
The Definition of Household Income
Household income is the sum of money income received in the calendar year by all household members 15 years old and over, including household members not related to the householder, people living alone, and other nonfamily household members. Included in the total are amounts reported separately for wage or salary income; net
The household income limits appearing in the table below are 1.9 times the 2014 Census Bureau definitions of poverty. The limits shown in the table are the limits that will be used to qualify residents for the
2014 INCOME MAXIMUMS FOR DETERMINING ELIBILITY FOR THE
Persons in family/household |
Income guideline |
|
|
For families/households with more than 8 persons, add $7,714 for each additional person.
1 |
$22,173 |
|
2 |
$29,887 |
|
3 |
$37,601 |
|
4 |
$45,315 |
|
5 |
$53,029 |
|
6 |
$60,743 |
|
7 |
$68,457 |
|
|
||
8 |
$76,171 |
|
|
||
|
|
|
Administrative Office: 14700 Potomac Mills Road, Woodbridge, VA 22192 Customer Info: (703)
Page 4 of 4