NT Taxi Subsidy Scheme Application - Department of Transport

Department of Lands and PlanningCommercial Passenger Vehicle BranchGPO Box 2520, DARWIN NT 0801Phone: (08) 8924 7580Fax: (08) 8924 7585Email: rtcpv@nt.gov.auWebsite: www.cpv.nt.gov.auNT Taxi Subsidy Scheme ApplicationCPVF30Please read these instructions before completing this form.EligibilityThe Northern Territory Taxi Subsidy Scheme (NTTSS) provides fi nancial assistance for taxi travel, of up to 50per cent of a taxi fare, for people with disabilities, or signifi cant mobility restrictions, who are dependent on taxisfor public transport. Taxi fares must be paid with combining the use of the NTTSS smartcard with payment ofcash and/or credit/debit card.The scheme is not intended to meet all costs associated with your travel and is subject to application criteriaand budgetary availability.CriteriaTo be eligible for NTTSS membership you MUST be a resident of the Northern Territory. You will be required toprovide proof of your permanent residential address e.g. current Centrelink card, current NT Driver’s Licence,Rates Notice (within the last 6 months), or Utilities account i.e Power/Water (within the last 6 months).Under the existing categories, you may be eligible to join this scheme if you are unable to safely utilisepublic transport due to:1. dependence on a wheelchair/scooter for all mobility outside of the home2. a disability with signifi cant mobility restrictions3. signifi cant visual impairment in both eyes4. severe and uncontrollable epilepsy, with seizures involving loss of consciousness5. signifi cant intellectual disability, memory or communicative impairment6. signifi cant psychiatric disability.The scheme does not assist people with mobility restrictions following acute injury, fracture or surgery.MembershipTo apply for membership you must complete an application form and Medical/Allied Health ProfessionalAssessment. You must also provide 2 passport size photographs (1 certifi ed).Applications may be approved on a permanent or temporary (between 6 and 12 months) basis. Membershipwill be temporary where an applicant has a condition that could improve with medical and/or surgical treatmentor rehabilitation.There are 5 categories of membership:Category DThis category is for very low or intermittent use, forapplicants who have a disabling condition that “fl aresup” from time to time e.g. arthritis.Category CThis category is for middle-range use, mostapproved applicants will receive this category.Category B MPVYou must be assessed as having to use a Multi-Purpose taxi for this category.Category BFor this category, you need to use a taxi at least fi ve(5) days a week on a regular basis and be fi nanciallydisadvantaged because of your transport needs.Category AApplicants with exceptional circumstances andconsiderable fi nancial hardship may apply forthis category. Ministerial approval of category Aapplications is required.Form CPVF30Effective Date:23 July 2009Page 1 of 12

Processing of ApplicationsApplication and assessment are required for membership of the scheme. Each application MUST be endorsedby your doctor/specialist or allied health professional and will be assessed on an individual basis.If eligibility is unclear, additional medical information may be sought from your doctor/specialist or allied healthprofessional. Applications are usually processed within 6 weeks of receipt. However, the assessment processmay be delayed if further information is required.Approved applicants will be sent an acceptance letter and an NTTSS smartcard by the Department of Planningand Infrastructure (DPI).Unsuccessful applicants will be advised in writing by DPI. Applicants may appeal the outcome in writing,addressed to the Taxi Subsidy Scheme Offi cer. Appeals will only be considered if additional relevant clinicalinformation supporting the severity of the disability is provided by a doctor/specialist or allied health professional.How to ApplyPart A – Page 4-6 must be completed by the applicant or the applicant’s carer or agent. Also the applicant’sdeclaration must be completed, signed and dated by the applicant or the applicant’s carer or agent.The declaration by the witness of the photograph and proof of residency must be completed, signed and datedon page 5. The Witness can be a health professional, a Justice of the Peace or Commissioner of Oaths, apolice offi cer or a solicitor, barrister or judge.Part B – Page 7 must be completed in addition to the relevant criterion selection on pages 8-10. The criterionand category recommendation on page 11 must be signed and dated by a doctor/specialist or allied healthprofessional.Completed application forms and associated paperwork should be sent to:Department of Lands and PlanningCommercial Passenger Vehicles BranchTaxi Subsidy Scheme OfficerPO Box 2520Darwin NT 0801PhotographsThe photographs must:• be no more than six months old,• be passport size, which is 45-50mm high and35-40mm wide,• be in colour, printed on photo-quality paper usinga high resolution,• have a plain, light coloured background,• show the applicant’s head and top of shoulders,• show the applicant looking directly at thecamera with eyes open, if possible,• show the applicant with his/her hat andsunglasses removed.The photographs must be attached to the top righthand corner of page 5 of this form with a paper clip. Donot pin, staple or glue your photographs to this form.The witness must write the following statementand provide their signature and date on the back ofone of the two photographs:FrontBack45-50mm35-40mmWitness must endorse photo:I certify this is atrue photograph ofApplicant‛s Full Namethe person in mypresence.Witness SignatureDD/MM/YY(Date)Form CPVF30Effective Date:23 July 2009Page 2 of 12

Part ATo be completed by the applicantor his/her authorised agentNT Taxi Subsidy Scheme ApplicationOFFICE USE ONLYNTTSS Member ID:CPVF30Please print clearlyApplicant’s DetailsSurnameGiven Name(s)Mr Mrs Ms Miss Other ...............................................Date of Birth/ /AddressResidential AddressPostal Address (if different to residential)PostcodePostcodeContact DetailsPhone (home):Phone (mobile):Phone (work):Fax:Email:Travel DetailsSocial, Entertainment, ReligiousShopping, BankingTrips per weekMedical, Dental, RehabilitationWork, School, StudyTrips per weekDo you require a wheelchair accessible taxi? Yes NoType of Pension/BenefitEmployedPension/Benefi t (tick box below)Aged PensionDisability Support PensionOther Govt PaymentVeterans Affairs PensionUnemployed Related Benefi tWorkers CompensationCarers PensionCDEPOtherMotor Vehicle Accident CompensationIf you answered yes to the above compensation questions, please specify benefi ts/entitlements:Mobility Allowance (from Centrelink): Yes NoForm CPVF30Effective Date: 23 July 2009 Page 4 of 12

Part A continued...Attach photographs here with paper clipHelpful NTTSS Member Photograph TipsDPI understands that obtaining passport sizephotographs may be a challenge for some currentand prospective NTTSS members. That is why DPI isaccepting alternative and slightly lower standards foridentifi cation photographs than what is accepted for theissuing of passports and driver licences.Both conventional and digital photography are acceptable, and conventional or digital printing methodsmay be used. However, digitally printed photos should be produced without visible pixels or dotpatterns. Photos are not to be manipulated, for example, by removing spots or softening wrinkles.Passport photos can be obtained from selected chemists, camera and photo developing shops.Passport photo booths, typically found in large shopping centres, may also produce photos of sufficientquality.With the accessibility and low cost of digital cameras and high quality home printers, passport photosmay be produced in a home environment. Digital cameras with a resolution of at least 2 megapixelsproduce passport sized images of sufficient quality.Witness’ Declaration of Applicant’s Photograph and Proof of ResidencyWitness’ Full NameI declare that (tick box):I meet the following requirement to make this declaration.HealthProfessionalJustice of the Peace, orCommissioner of OathsPoliceOffi cerSolicitor, Barristeror JudgeI am satisfied that the photograph witnessed by myself represents the applicant’s true identity. Yes NoI am satisfi ed that the document presented by the applicant as proof that the applicant is a resident of theNorthern Territiory is current (i.e. not expired), or in the case of a rates notice or utility account not morethan six months old.Centrelink CardNT Driver LicenceUtilities AccountOther (please specify)Rates NoticeWitness’ Signature Witness Phone No. Date/ /Form CPVF30Effective Date: 23 July 2009 Page 5 of 12

Part A continued...Applicant’s DeclarationI declare that the information provided in this application is complete, true and correct in every detail.I consent to my doctors, specialists or other health professionals providing DPI with anypersonal, health or other information required to assess my application to the NTTSS. Ifrelevant to the application, I also consent to Centrelink confirming my concession eligibility forthe purpose of NTTSS assessment.I understand that I may be interviewed if insuffi cient information has been provided for assessment.I understand that if my application is approved and a subsequent review of my continued eligibility formembership is required, I may be required to be interviewed at that time.If this application is approved, I undertake to observe the conditions governing the granting of thesubsidy and acknowledge that failure to do so may lead to my withdrawal from the scheme.I understand that costs associated with the completion of this form are my responsibility.Privacy Statement: The personal information contained in your application will be used to assessyour entitlements for the NTTSS. Consistent with NT Government legislation and policy, we take allreasonable steps to protect the privacy of your personal and health information. We will only releaseyour personal information with your consent or where this is permitted or required by law. You are ableto request access to the information held about you by contacting the Taxi Subsidy Scheme Offi cer.Cabcharge Australia is contracted by DPI to produce NTTSS member smartcards. Your name,membership number, address and photograph will be disclosed to Cabcharge Australia for thepurposes of producing your NTTSS member smartcard. After your smartcard has been dispatchedto you, Cabcharge Australia will return your photograph to DPI. Cabcharge Australia will not store orrelease your name, address or photograph.Applicants Signature Agents Signature Agents Contact Phone No. Date/ /Agent/Carer NameAgents Relationship to ApplicantForm CPVF30Effective Date: 23 July 2009 Page 6 of 12

Part BTo be completed by your Doctor/Specialistor Allied Health ProfessionalNT Taxi Subsidy Scheme ApplicationOFFICE USE ONLYNTTSS Member ID:CPVF30Guidelines for specified health professionalsselect the appropriate criterion from page 1• answer questions Q1 to Q7 below• complete details for the selected criterion as indicated in Q7 below• sign and date the selected criterion/category on page 11• stamp or print contact details clearly• advise applicant of requirement for two photographs (1 certifi ed)• certify one photograph if requested and complete witness declaration on page 5The following reasons are not grounds for approval• diffi culty in accessing bus due to availability, timetable, remoteness or terrain• fi nancial constraints• pension/concession card eligibility• inability to drive• disability occurring in the recovery period following acute illness, injury or surgeryFailure to provide sufficient relevant information, as requested on this application, could result inineligibility or a request for further information and may delay the assessment process.Please tick the relevant boxMedical Practitioner Medical Specialist Allied Health ProfessionalPublic TransportQ1. Is this applicant able to use Public Buses? Yes NoQ2. If Yes, how often? Always IntermittentlyQ3. For approximately how long has this applicant been in your care?(e.g. 5 years or fi rst consultation)Q4. Do you consider the applicant to have signifi cant mobility restrictions? Yes NoQ5. Is the severity of the applicant’s condition expected to substantiallyimprove, such that he/she will be able to use public transport in thefuture e.g. following major surgery?YesNoQ6. If Yes, when do you expect this to occur (indicates temporary status)? Date / /Q7. Indicate ONE criterion from the list below relevant to this application.Criterion 1 Complete page 8(dependence on a wheelchair mobility device)Criterion 2 Complete page 9(signifi cant mobility restrictions)Form CPVF30Criterion 3 Complete page 9(signifi cant visual impairment)Criterion 5 Complete page 10(signifi cant intellectual disability,memory or communication impairment)Criterion 4 Complete page 9(severe and uncontrollable epilepsy)Criterion 6 Complete page 10(signifi cant psychiatric disability)Effective Date: 23 July 2009 Page 7 of 12

Part Bcontinued...NT Taxi Subsidy Scheme ApplicationCPVF30ONLY ONE CRITERION is required for eligibility to the NTTSS, please complete ONE relevant criterion.Criterion 1: Dependency on wheelchair/mobility deviceCriterion 1 applications are to be completed by a Medical Practitioner/Specialist or Allied Health Professional.Does the applicant use a mobility aid? Yes NoWhere is the aid used? Indoors OutdoorsWhat is the frequency of use? Always OccasionallyDescribe the type of mobility aid used(e.g. wheelchair, crutches, walker, stick)Is the applicant dependant on a wheelchair or other device for mobility? Yes NoIs this client able to use his/her wheelchair or mobility device independentlyon a daily basis?YesNoDoes the applicant require assistance from another person for mobility? Yes NoIs the applicant able to stand from sitting independently? Yes NoCan the applicant ascend and descend 3 steps independently (using rail)? Yes NoHow far can the applicant walk before needing to rest due to the severityof symptoms?Independently without aid:With mobility aid (if used):Is this client able to independently transfer from wheelchair/mobility deviceto a car? If yes, client will not require a wheelchair Taxi.YesNoIs the client able to independently use and access a public transport bususing a wheelchair or mobility device?YesNoForm CPVF30Effective Date: 23 July 2009 Page 8 of 12

Part Bcontinued...NT Taxi Subsidy Scheme ApplicationCPVF30Criterion 2: Significant mobility restrictionsCriterion 2 applications are to be completed by a Medical Practitioner/Specialist or Allied Health Professional.What symptoms does this client have that signifi cantly limits his/her mobility?Balance Pain Shortness of breathFatigueOther, please specify:Is this client able to complete normal community activity e.g. shopping usingpublic transport?If no, please provide details:YesNoCriterion 3: Significant visual impairment in both eyesCriterion 3 applications are to be completed by an Ophthalmologist or Low Vision Co-ordinator/Assessor. Thisapplicant must have signifi cant visual impairment, with eligibility for the Disability Support Pension (Blind) orAged Pension or have a similar level of severe visual impairment.Does this applicant receive the Disability Support Pension (Blind) or AgedPension?Specify visual impairment:Outline why this client cannot use public transport:YesNoCriterion 4: Severe and uncontrollable epilepsyCriterion 4 applications are to be completed by a General Practitioner/Medical Specialist. Applicants with epilepsyin a stable condition as a result of medication are not eligible for this scheme. Membership under this criterion isavailable for a maximum period of 12 months. After this time a further application will be required.Does this client have a recent history of uncontrollable seizures? Yes NoIs there loss of consciousness? Yes NoHow many seizures has the applicant had in the last 3 months?What was the approximate date of the applicant’s last seizure? / /Has the applicant been reviewed by a specialist in the last twelve months?(provide details below)YesNoLast review date: / /Is this client able to independently travel in a Taxi? Yes NoForm CPVF30Effective Date: 23 July 2009 Page 9 of 12

Part Bcontinued...NT Taxi Subsidy Scheme ApplicationCPVF30Criterion 5: Intellectual disability, memory or communication impairmentCriterion 5 applications are to be completed by a Medical Practitioner, Specialist or Allied Health Professional.This criterion applies to applicants with signifi cant cognitive impairment and includes people with dementia.Does this client have an intellectual/behavioural disability or Communicationimpairment such that he/she is unable to access public transport withoutassistance?YesNoIs this client able to independently travel in a taxi? Yes NoIs this client able to independently travel in a taxi if he/she is met at bothends of the trip?Does this client have serious communication diffi culties, such that he/sheis unable to interact with the public transport system e.g. buy a ticket,locate correct bus stop etc?Is this client likely to become aggressive, highly anti-social or self-harmingdue to his/her disability if he/she uses the public transport system?Is this client likely to become seriously disoriented or confused if he/sheuses the public transport system?YesYesYesYesNoNoNoNoCriterion 6: Significant psychiatric disabilityCriterion 6 applications are to be completed by a Medical Practioner, Psychiatrist or a Psychologist. Thiscriterion applies to applicants with significant psychiatric disabilities.Does this client have a serious psychiatric condition such that he/she isunable to interact with the public transport system e.g. buy a ticket, identifythe correct stop?YesNoIs this client able to independently travel in a taxi? Yes NoIs this client able to independently travel in a taxi if he/she is met at bothends of the trip?Does this client have serious communication diffi culties, such that he/sheis unable to interact with the public transport system e.g. buy a ticket,locate correct bus stop etc?Is this client likely to become aggressive, highly anti-social or self-harmingdue to his/her disability if he/she uses the public transport system?Is this client likely to become seriously disoriented or confused if he/sheuses the public transport system?YesYesYesYesNoNoNoNoForm CPVF30Effective Date: 23 July 2009 Page 10 of 12

Part Bcontinued...NT Taxi Subsidy Scheme ApplicationCPVF30RecommendationIt is recommended that this client be granted membership to the NTTSS:Temporary (6 to 12 months basis)ORPermanentIndicate eligibility criterion and rationale for category recommended.Criterion 1: Dependency on wheelchair/mobility deviceCategory D Category C Category B Category B MPVRationale:Criterion 2: Significant mobility restrictionsCategory DCategory CRationale:Criterion 3: Significant visual impairment in both eyesCategory DCategory CRationale:Criterion 4: Severe and uncontrollable epilepsyCategory DCategory CRationale:Criterion 5: Intellectual disability, memory or communication impairmentCategory DCategory CRationale:Criterion 6: Significant psychiatric disabilityCategory DCategory CRationale:Contact Details - Medical Practitioner/Specialist/Allied Health ProfessionalName:Date / /Contact Phone number:Signature:Form CPVF30Effective Date: 23 July 2009 Page 11 of 12

Part CTo be completed byNTTSS delegated offi cerNT Taxi Subsidy Scheme ApplicationOFFICE USE ONLYNTTSS Member ID:CPVF30Please tick the relevant answerRecommendationAre you recommending approval of this application?YesNoDuration:6 months 12 months PermanentCategory:D C B B MPV AIf no, you MUST give reasonsReview Date: / /Rationale for decision:Name of delegated offi cer:(please print clearly)Signature:Date / /Office Use OnlyClient notifi ed of decision (letter sent)Form CPVF30Yes No NTTSS card issued Yes NoEffective Date: 23 July 2009 Page 12 of 12