Paratransit Eligibility Form

Personal Data Card, Certification and Authorization for Release of Protected Health Information 

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.

Section 1:  Personal Data    
  
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:__________________________
Mobile Phone Number of Person Assisting:______________________
Email of Person Assisting:____________________________________


Address of Applicant: _________________________________________________________	
City: __________________State: ___________Zip: _______________

Phone Number(s) of Applicant:________________________________
Mobile Phone Number of Applicant:____________________________
__________________________________________________________
Best time(s) to call:  __________________________________________________________
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:____________________________________________________
City: _________________________State:_____________Zip: ________
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:________________________ 

Section 3:  Authorization for Release of Protected Health Information
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:
Name: ____________________________________________________________
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: ______________