Application for Paratransit Services ADA ... - Lake County

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