Application for Paratransit Services ADA ... - Lake County

LAKE COUNTY PUBLIC TRANSPORTATIONAPPLICATION FOR PARATRANSIT SERVICESAMERICANS WITH DISABILITIES (ADA) COMPLIMENTARY SERVICESLake County provides two types of public transportation:Lake County Connection is a “door-to-door” shared ride paratransit serviceprovided only to individuals with disabilities that cannot use LakeXpress and thatmeet certain eligibility requirements.LakeXpress is the “fixed route” public transportation system which is open to thegeneral public. (No eligibility requirements.) Passengers go to a bus stop or to asafe point along the bus route and wait for the bus. (Until sufficient bus stop signsare installed, passengers may “flag” down the fixed route bus at safe locations onthe route.)INSTRUCTIONS FOR COMPLETING THIS APPLICATIONPlease fill out the application completely. A LICENSED PROFESSIONAL MUSTCOMPLETE SECTION D, IF APPLICABLE.The certification process may involve a telephone interview. All questions mustbe answered.INCOMPLETE APPLICATIONS WILL BE RETURNED. IF THE INFORMATIONIS NOT PROVIDED WITHIN 30 DAYS THE APPLICATION WILL BE DENIED.If you have any questions or need assistance completing this application, pleasecall our Customer Service Department at (352) 326-2278 ext. 3.PROCESSING OF THIS APPLICATION MAY TAKE UP TO 21 DAYS.WHEN COMPLETED, PLEASE RETURN THE APPLICATION TO:Lake County ConnectionP.O. Box 491597Leesburg, FL 34749DO NOT WRITE IN THIS SPACENew Application: _________________________Date Received: __________________________Reviewed By: ____________________________Bill Code: _______________________________PCA Needed: Yes: __________ No: ___________Re-certification: _________________________Approved: __________ Date: ______________Denied: ____________ Date: ______________Third Part Review: ____ Date: ______________Fixed Route Referral Y/N Date: _____________ADA ApplicationRevised 6/23/10

INSTRUCTIONS FOR COMPLETING THIS FORMPlease read the enclosed paratransit eligibility criteria carefully. If you feel thatyou meet these criteria, please fill out the applicable sections of this form.Be sure to print and complete all information requested and sign whereappropriate.Section D, Professional Verification, must be completed and signed by anapproved health care professional or proof of social security disability or otheracceptable documentation must be submitted with your application. Informationmay be verified.Lake County Public Transportation provides paratransit services in speciallyequipped vans and sedans to persons who cannot use the regular bus system(LakeXpress). This service is provided under Lake County Connection, our doorto-doorservice.To be eligible for Lake County Public Transportation Americans with Disabilitiescomplementary services, individuals must have disabilities that prevent them frombeing able to use or access LakeXpress, the fixed route bus system. Age,income, access, nor the distances to the nearest bus stop alone qualify as eligibledisabilities.Any false or misleading statements will be cause for revoking paratransit eligibility.Determination of paratransit eligibility is not based solely on the information givento us in this application. The applicant may be required to participate in ourFunctional Assessment interview to determine the best mode of transportation.The applicant will be notified by mail to schedule an appointment for theFunctional Assessment.Incomplete or illegible applications will be returned causing a delay of theApplicant’s eligibility determination.Federal guidelines mandate that determinations for paratransit eligibility be madewithin 21 days from receipt of a completed application.Applicants will be granted presumptive eligibility if determination has not beenmade within the 21 days of the submission of the completed application.ADA ApplicationRevised 6/23/10

SECTION 1 – GENERAL INFORMATION New Recertification Female MalePLEASE PRINTLast Name: ________________First Name:Middle InitialDate of Birth: __________Social Security No.: _________________Medicaid No: ______________________Street Address:Apt. No: ______City: __________________________ State: ________ Zip Code: ____________Subdivision or Apartment Name: ________________________________If this is a “gated community” please provide the gate code: _________________Nearest intersecting street: ___________________________________________Mailing Address if different than above:City: __________________________ State: ________ Zip Code: ____________Home Phone:Work Phone:Cell Phone:Email:Please provide information for someone we can contact in case of an emergency:Name:Home Phone:Relationship: _____________________Cell Phone:Do you require materials or correspondence in an alternative format?_____Yes _____NoIf yes, please list acceptable formats:Lake County Board of County Commissioners and our Operator, MVTransportation, Inc. collects your social security number for the followingpurposes: identification and verification, billing and payments and benefitprocessing. Social security numbers are used as a unique numeric identifier andmay be used for search purposes.ADA ApplicationRevised 6/23/10

APPLICANT RELEASEI understand that the purpose of this evaluation application is to determine myeligibility for Lake County Connection paratransit service.I understand that the information about my disability contained in this applicationwill be kept confidential and the information may be verified with my health careprofessional.I hereby authorize my medical representative to release the pertinent medicalinformation regarding my condition to Lake County Connection if requested.I understand that providing false or misleading information could result in myeligibility status being revoked.I agree to notify Lake County Connection within 10 days, if there is a change incircumstances or I no longer need to use paratransit services.___________________________Applicant’s Signature_________________________DateIf applicant is unable to sign this form, he/she may have someone sign onhis/her behalf. I am signing on behalf of _____________________________._______________________ ______________________ __________Signature Relationship to Applicant DatePlease check which condition(s) prevents you/the applicant from accessing theregular Lake Express fixed route bus system._______________None, I’d rather use the door-to-door service.(Please complete Section A only.)The bus stop is too far or the bus does not run where I need to go.(Please complete Section B only.)My disability prevents me from using the regular bus system.(Please complete Section C and Section D only.)ADA ApplicationRevised 6/23/10

SECTION A1. How do you currently travel to your destinations?LakeXpress ____ Lake County Connection ____Taxi ____Drive myself ____ Other ____2. Do you have friends or relatives who can take you?Yes ____ No ____3. What is your annual household income? ___________________________4. How many people (including yourself) are in your household? __________5. Have you in the past 2 years, qualified for public assistance?Yes ____ No ____6. Do you have weekly scheduled medical appointments (such as dialysis,etc)?Yes ____ No ____If yes, please list: ______________________________________________7. How many medical appointments do you have a month?1-2 ____ 3-4 ____ 5-6 ____ More than 7 ____8. Do you or anyone in your household own or have a car?Yes ____ No ____ (Information may be verified by DMV)9. Would you like to ride LakeXpress if you were provided with a bus pass?Yes ____ No ____10. Do you have any of the following? (Please check all that apply.)____ I am on portable oxygen____ I have a sight impairment____ I am totally blind____ I need assistance walking____ I use a cane____ I need an escort____ I must travel by wheelchair____ I have a personal care attendant____ I have a medical impairment____ I am legally blind____ I have a hearing impairment____ I use a walker____ I have a service animal____ I use crutches____ I must travel by stretcher_______________________________Applicant’s NameADA ApplicationRevised 6/23/10

SECTION B – PAGE 1 OF 21. How close is the nearest bus stop to your home?_____________________________________________________________2. Do you currently ride Lake County Connection busses?Yes ____ No ____3. Have you used Lake County Connection service in the past 6 months?Yes____ No ____If no, why not? _____________________________________________________________________________________________________________4. What are your transportation needs? ____________________________________________________________________________________________5. How do you currently travel to your destinations?LakeXpress ____ Lake County Connection ____Taxi ____Drive myself ____ Other ____6. Do you have weekly scheduled medical appointments (such as dialysis,etc)?Yes ____ No ____If yes, please list ___________________________________________________________________________________________________________7. How many medical appointments do you have a month?____ 1-2 ____ 3-4 ____ 5-6 ____ More than 78. Do you or anyone in your household own or have a car?Yes ____ No ____ (Information may be verified by DMV)9. Would you like to ride LakeXpress if you were provided with a bus pass?Yes ____ No ____10. Does the bus go where you want to go?Yes ____ No ____ADA ApplicationRevised 6/23/10

SECTION D – PROFESSIONAL VERIFICATIONMUST BE COMPLETED BY A LICENSED PROFESSIONALThe applicant is requesting certification to use Lake County Connectionparatransit service. Lake County Connection is a door-to-door, shared rideprogram for individuals with physical or cognitive disabilities who are unable to useor access the regular fixed route public transportation service.Please complete the medical verification section of this application. Theinformation you provide must be based solely upon the applicant having an actualphysical or cognitive limitation, which prevents the use of our bus service.The diagnosis of a potentially limiting illness or condition is not sufficientdetermination for paratransit services.What is the applicant’s disability?__________________________________________________________________________________________________________________________________How does this condition functionally prevent the applicant from using the regularbus service?__________________________________________________________________________________________________________________________________What other normal life functions are prevented by the disability?__________________________________________________________________________________________________________________________________Is the applicant’s disability: Permanent _____ Temporary _____If temporary, what is the estimated duration of the disability?___________________________________________________________________________________________________________________________________________________________________________Signature of Approved Health Care Professional__________________________________________________________Professional License Number___________________Date___________________________State IssuedPrint Name________________________________Business Address _________________________________________________City State Zip CodePhone Number ___________________Fax Number _________________ADA ApplicationRevised 6/23/10