Prtc Online Application Form – Fill Out and Use This PDF

Enter your Name, Address, City and Zip Code.

Enter the Telephone number for Day and for Evening.

Mark Male or Female, and enter the Date of Birth.

Enter the Social Security number, last four numbers only.

To qualify for the Wheels-to-Wellness Program, applicants can NOT be eligible for non-emergency Medicaid transportation through the Virginia Department of Medical Assistance Services, MUST live in a low-income household, and MUST be 80 years or older or have a disability as defined by the Americans with Disabilities Act.

The combined household income must be not more than 1.9 times the federal poverty level. Verification is required.

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.

Enter the Number of persons in household.

If you are 80 years or older, mark I am 80 years or older, and attach a photocopy of a government-issued photo ID showing date of birth.

If you have a disability as defined by the Americans with Disabilities Act, mark I have a disability, and you must have a certifier complete Part II.

Mark each Transportation Accommodation you require: Wheelchair, Walker, Service Animal (If other than dog, specify), Companion, or Other, please explain.

Print and sign to certify that the information provided is true and accurate to the best of your knowledge.

Misrepresentation of any information may result in suspension or termination of your program enrollment and transportation assistance.

You may be required to reimburse the Wheels-to-Wellness program for any monies afforded you as a result of providing inaccurate information or through the misuse of the electronic purchasing card issued to you under the program rules.

The proof of residency document must show your name and the 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.

An acceptable document is a 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.

Other acceptable documents include a payroll check stub issued by an employer within the last two months, an original monthly bank statement not more than two months old issued by a bank, and a Virginia driver's license, learner's permit or DMV photo ID card displaying the applicant's current Virginia address.

Enter the Applicant Name in Part II. Part II is 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.

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.

Mark Is the disability permanent? or Is the disability temporary? If temporary, enter for how long (in months).

If you provide a temporary date, you will re-apply upon the expiration date.

Mark Yes or No for each of the following. Has a medical condition that prevents him/her from using a seat belt.

Must travel with an escort or companion: mark Yes or No. If Yes, applicant will be required to travel with an escort at all times.

Requires the assistance of a service animal in order to travel: mark Yes or No.

This information reflects professional judgment that the applicant is eligible according to the criteria established here.

The certifier enters Certifier's Name, Profession, Address, Telephone Number, Registry/State Certification Number, signature and Date.

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 non-profit organization at a facility in the Greater Prince William area.

Mail the completed form to the Potomac and Rappahannock Transportation Commission (PRTC) or fax it to (703) 583-1702.

An enrollment fee of $15.00 is due upon enrollment (checked November 7, 2026).