Paratransit
Eligibility Form Please read, sign, date and
mail or drop off at OUTREACH, 926 Rock Avenue, Suite 10, San Jose, CA 95131
(or) FAX to (408) 382-0470. This form may be downloaded at www.outreach1.org
or www.vta.org If you need help completing this form, call OUTREACH and
we will be pleased to assist over the phone: 408-436-2865. OUTREACH will contact
you for a phone interview. Check one: New
Applicant_______ Existing Customer_____ (Outreach ID # if Existing
Customer:_______________________) Applicant
Name:___________________________________________ (Mr/Mrs/Ms – circle one) Name of Person Assisting
Applicant (if any): _________________________________________________________ (Mr/Mrs/Ms – circle one) Relationship to
Applicant: ___________________________________ Phone Number(s) of
Person Assisting:__________________________ City:
__________________State: ___________Zip: _______________ Best time(s) to call:
__________________________________________________________
Personal Data Card, Certification and Authorization for Release of Protected
Health Information Section 1: Personal Data
Mobile Phone Number of Person Assisting:______________________
Email of Person Assisting:____________________________________
Address of Applicant:
_________________________________________________________
Phone Number(s) of Applicant:________________________________
Mobile Phone Number of Applicant:____________________________
__________________________________________________________
Email: ____________________________________________________
Primary Language: __________________________________________________________
What is your primary disability and/or most limiting condition?
_________________________________________________________
_________________________________________________________
Do you use any mobility
aids or specialized equipment?
_____Yes _____No
If you answered “Yes” please check all that apply:
____Cane ____White
Cane ____Walker ____Crutches
____Manual Wheelchair
____Power Wheelchair _____Power Scooter
_____Leg Braces ____Respirator ____Portable Oxygen Tank
_____Prosthesis ____Service Animal ____Speech Devices
_____Communication Board Other (specify):____________________
Do you need any future written information provided to you in an accessible format? Yes _____ No ______
If “Yes”, please check the format you prefer: _____Email _____Diskette _____Audio Tape _____Braille _____Large Print
Emergency Contact Name:
___________________________________________________________
Relationship to Applicant: _____________________________________
Address:____________________________________________________
Phone Number(s):____________________________________________
Cell Phone Number:__________________________________________
Section 2: Applicant Certification (Please sign)
I certify that the information provided during the application process is true and correct to the best of my knowledge. I understand that falsifying the information will result in a denial of service and may result in criminal penalty.
Applicant Signature: ______________________________Date:________________________
I understand the protected health information provided during the application and interview process will be kept confidential and shared only with the following professionals or providers as necessary to determine eligibility and provide paratransit services, and for quality assurance/audits to comply with ADA regulations and VTA policy: VTA, OUTREACH and their eligibility representatives, and their contractors.
Section 4: Authorization to Release Medical Information
(Please include the contact information for your physician or licensed professional, who can verify your disability/ies, or has knowledge about your disability/ies and functional limitations.)
I hereby authorize:
Address: ____________________________________________________________
Phone: ___________________________FAX:______________________________
to release the information requested below about my disability or disabilities to OUTREACH eligibility representatives/contractors upon request. The information released will be used solely to evaluate my eligibility for VTA paratransit services as required by the Americans with Disabilities Act, 42 U.S.C. Section 12101 et seq., 104 Stats. 327. I understand that I have a right to revoke any Section of this authorization at any time by writing to OUTREACH, except to the extent that action has already been taken based upon this authorization.
Applicant Signature:
__________________________________________
Date: ______________