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

Please read, sign, date and mail or drop off at 
OUTREACH, Inc., 926 Rock Avenue, Suite 10, San Jose, CA 95131 (or) FAX to (408) 382-0470. 

This form may be downloaded at http://www.outreach1.org or http://www.vta.org  

Applications- for individuals who are under the age of 18 years, must be completed by 
the applicant's parent, legal guardian or custodian. 

If an applicant is 18 years or older, but is unable to complete the application because 
of a physical or vision impairment, the applicant must have given permission to the person 
completing the application. 

Applications for individuals 18 years of age or older with cognitive impairments, must be 
completed by the applicant's legal guardian or custodian.

Applications that do not meet the above criteria will not be processed. Thank you in 
advance for your cooperation.

OUTREACH will contact you for a phone interview.

Section 1: Personal Data

Check one: 
New Applicant _______

Existing Customer _______

Outreach ID # _______________________

Applicant Name: ___________________________________________ 	
(Mr/Mrs/Ms - circle one)

Birthdate: ________________

Application Information: 
Address: __________________________________________________________

City: _________________________________________

State: ______

Zip Code: ____________

Home Phone Number: ____________________________

Cell Phone Number: ____________________________

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 ____  

Manual Wheelchair ____	

Power Wheelchair ____ 	

Power Scooter ____

Leg Braces ____ 

Prosthesis ____

Service Animal ____

Speech Devices ____

Crutches ____

Respirator ____

Communication Board ____ 
 
Portable Oxygen Tank ____
 
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 ____

Would you be interested in learning more about mobility options and travel training? 

Yes ____

No ____

Emergency Contact Name: _________________________________________

Relationship to Applicant: ______________________________________

Phone Number (s): _______________________________________________

Address: ________________________________________________________

City: _______________________________

State: ____________________

Zip Code: _________________


Section 2: 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 3: 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: __________________________

(OPTIONAL) Medical Record/Kaiser Number: __________________________


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: __________________________

Section 4: Applicant Certification (Please sign)

All applicants must sign the completed application. If this application has been completed 
by someone other than the person requesting certification, the person who completed the 
application must provide the following information:

Name of Person Assisting Applicant: __________________________________________________________

Relationship to Applicant: __________________________________________________________

Address: __________________________________________________________			

City: _______________________________

State: ________________

Zip Code: ______________

Phone Number: _______________________________

Alternate Number: ________________________________

Signature: _______________________________________

Date: __________________________

By signing this application, you are certifying under penalty of perjury under the laws of 
the State of California, that the foregoing is true and correct.

Applicant/Legal Guardian/Conservator Signature: ___________________________________


Date: ____________________