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The ride application
 

The ride application

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    The ride application The ride application Document Transcript

    • Dear RIDE Applicant:Thank you for your interest in THE RIDE, the MBTA’s shared-ride, door-to-door transportation program for persons who are prevented fromindependently using the fixed-route services such as buses, subway trains,and trolleys (not including commuter rail and boat) due to barriers incombination with their disability(ies) for some or all trips.Please have the application fully completed by you and yourlicensed/certified human services or health care provider prior to returning itto us. All information provided is confidential and serves to determineeligibility only. Sincerely, Office for Transportation Access—THE RIDE ProgramVisit our website for more information about THE RIDE at www.mbta.com,and then navigate to “Riding the T—Accessible Services—THE RIDE”. Ifyou have any further questions or require an accommodation, please callthe Office for Transportation Access—THE RIDE Program, at 617-222-5123(Voice), 800-533-6282 (Toll-free Voice), 617-222-5415 (TTY), or emailtheride@mbta.com. We look forward to ensuring that public transportationis available for persons of all abilities. INSTRUCTIONS PAGE 1
    • INSTRUCTIONS FOR THE RIDE APPLICATIONPlease complete each section. If there are questions that you do notunderstand, please do not hesitate to call 617-222-5123 or emailtheride@mbta.com.The purpose of this application is to identify the functional limitations andbarriers which prevent you from independentlyusing MBTA fixed route services buses, subway trains, and trolleys (notincluding commuter rail and boat) some or all of the time. It is important thatyou and your licensed/certified human services or health care providersupply specific, detailed responses so we may understand your abilities andassess your eligibility.• You, the applicant, should complete pages 1 through 7 of the application.• A licensed/certified human services or health care provider only needs to complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Epilepsy or Seizure Disorder, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if applicable.• Examples of professionals include: Medical Doctor, Psychiatrist, Psychologist, Social Worker (LSW, LCSW, LICSW), Rehabilitation Professional, Physical/Occupational Therapist, Certified Orientation and Mobility Specialist (COMS), Physicians Assistant, Nurse Practitioner, and Registered Nurse.• Please attach any documentation that should be considered as part of the application for Paratransit eligibility.• When application is fully complete, please mail signed original to: MBTA Office for Transportation Access/ THE RIDE Ten Park Plaza, Room 5750, Boston, MA 02116 INSTRUCTIONS PAGE 2
    • ELIGIBILITY CRITERIAThe RIDE adheres to the American with Disabilities Act (ADA) of 1990eligibility standards for paratransit services. The law is specific in definingeligibility for ADA complementary paratransit services. A person must havea physical, cognitive or mental limitation, which prohibits his/herindependent use of accessible fixed route public transportation.Category 1 Individuals who, as the result of a physical (including visualimpairments), mental, or emotional impairment, and without the assistanceof another individual (except the operator), cannot board, ride, or disembarkfrom an accessible vehicle some or all of the time.Category 2 An individual who can independently use an accessiblevehicle, but none is available on his/her route some or all of the timeCategory 3 Individuals who have a specific-impairment relatedcondition that prevents getting to/from a stop within the service areasome or all of the time.Eligibility criteria does not include: Age, lack of service in your town,beyond ¾ miles from fixed route services, inconvenience, discomfort,financial status, or ability to drive. A diagnosis of a potentially limiting illnessor condition is not sufficient; you and your provider must describe how yourdisability prevents you from getting to, boarding/disembarking, and/orriding on fixed route transit services independently.When completing your application, assess your potential travel throughoutthe entire bus and/or rail system during all seasons, not just those in yourimmediate neighborhood or those that you normally use. INSTRUCTIONS PAGE 3
    • APPROVED CATEGORIES OF ELIGIBILITYOnce determined eligible for the MBTA RIDE Paratransit service youwill be assigned an eligibility category. The eligibility category isconsistent with your ability to use fixed route transit. These categoriesinclude:Unconditional - Individual is not able to use accessible fixed routetransit under any circumstances and is eligible for all trips on theparatransit serviceConditional - Individual is not able to use accessible fixed route transit inspecific circumstances and is eligible to use the paratransit service underlimited circumstances identified. For example, conditional categoriesinclude: • Night: Individual is eligible for service from dusk to dawn. • Heat: Individual is eligible for service when temperatures are above 80 degrees. • Cold: Individual is eligible for service when temperatures are below 35 degrees. • Snow/ice: Individual is eligible for service when snow or ice is present. • PCA Always: Individual is required to travel with a personal care attendant for safety. • Met on Both Ends: Individual is required to be met by someone at pickup/drop-off locations for safety.Temporary - Individual is not able to use accessible fixed route (bus, train,trolley) transit at this time, however the condition or circumstance(s) leadingto eligibility is reasonably expected to improve in the future. INSTRUCTIONS PAGE 4
    • APPLICATION SUBMISSIONOnce your application is received, the Eligibility Review Committee willreview it. After the eligibility determination is made, we will notify you inwriting. Please allow 21 days from the day we receive your completedapplication for processing.Call the Office for Transportation Access if you have any questions aboutthe decision. If your eligibility determination has not been made within 21days of receipt of your completed application, you will be granted THE RIDEservice until the determination is made.If you have any questions about the application or you want to check thestatus of your application, contact the Office for Transportation Access at800-533-6282 (Toll-free Voice),617-222-5123 (Voice), or 617-222-5415 (TTY) for the deaf and hard ofhearing. ABOUT THE RIDE SERVICEThe MBTAs paratransit service, THE RIDE, provides advance notice,shared-ride, door-to-door transportation to those who, because of a mental,physical or cognitive disability, are unableto use fixed-route public transportation.As a customer of this shared-ride service, you will travel with otherpassengers on vehicles that operate within a 60 city and town service area.(See enclosed listing of communities). Greater detail on use of the servicewill be provided upon completion of the registration process. INSTRUCTIONS PAGE 5
    • ADDITIONAL MBTA RESOURCES AND CONTACTS• Visit www.mbta.com for transit updates, accessibility, and travel information• Call our Customer Communications Center at 800-392-6100 (Toll-free Voice), 617-222-3200 (Voice), or 617-222-5146 (TTY) for accessibility related questions concerning MBTA buses, subway, commuter trains or boats, or for travel information.• MBTA Senior and Access Program Information o www.mbta.com Riding the T Accessible Services Reduced Fare CharlieCard (buses, subways and trains, commuter rail and boat) for seniors and persons with disabilities are available at Back Bay Station on the Orange Line. For information, call 800- 543-8287 (Toll-free voice), 617-222-5438 (Voice), 617-222-5854 (TTY).• Elevator / Escalator Update Line o 800-392-6100, press 6 or www.mbta.com ‘Rider Tools’ o 617-222-2828 (Voice), 617-222-5854 (TTY), Mon. - Fri., 8:30 a.m. - 5:00 p.m.• The Access Advisory Committee to the MBTA (AACT) is a consumer body that advises and makes recommendations to the MBTA regarding accessible transportation. Anyone is invited to participate. The goal of AACT is to achieve 100% accessible transportation. AACT meets monthly at the State Transportation Building, 10 Park Plaza in Boston. For meeting information or to be placed on their mailing list call 617-973-7507(Voice), 617-973-7089 (TTY) or email aact@ctps.org. INSTRUCTIONS PAGE 6
    • CITIES AND TOWNS IN THE MBTA SERVICE AREA Boston North Northwest South GLSS VTS JV Allston Beverly Arlington Boston Back Bay Boston Bedford Braintree Brighton Chelsea Belmont Canton Charlestown Danvers Boston Cohasset Chinatown Everett Brookline Dedham Dorchester Lynn Burlington Dover Downtown Lynnfield Cambridge Hingham Boston East Boston Malden Concord Holbrook Fenway Marblehead Lexington Hull Hyde Park Melrose Lincoln Medfield Jamaica Plain Middleton Medford Milton Mattapan Nahant Newton Needham North End Peabody Somerville Norwood Roslindale Reading Waltham Quincy Roxbury Revere Watertown Randolph South Boston Salem Weston Sharon South End Saugus Wilmington Walpole West Roxbury Stoneham Winchester Wellesley Swampscott Woburn Westwood Topsfield Weymouth Wakefield Wenham WinthropFor information on Massachusetts cities and towns not serviced by THERIDE program, visit massdot.state.ma.us/Transit and navigate to RegionalTransit link, or call 617-973-7000 (Voice) or 617-973-7306 (TTY). Serviceavailability, hours of service, fares and policies vary in other areas. INSTRUCTIONS PAGE 7
    • THIS PAGE INTENTIONALLY LEFT BLANK INSTRUCTIONS PAGE 8
    • MBTA Use Only I.D. #:_____________________ THE RIDE Paratransit Eligibility Application Date:_____________________Send original (not fax or copy) to: Questions? Contact us at:MBTA Office for Transportation Access theride@mbta.comTen Park Plaza, Room 5750 800-533-6282, 617-222-5123(V)Boston, MA 02116 617-222-5415(TTY) I. GENERAL INFORMATION: PLEASE TYPE/PRINT CLEARLY  MaleApplicant Name _________________________________________  Female First Middle Initial LastHome Address________________________________________ Apt. _______City __________________________ State________ Zipcode_________Email ___________________________________Date of birth____ /____ /____  Voice  Voice  VoicePhone ____________  TTY ____________  TTY______________  TTY Home Work CellMailing address __________________________________ Apt.________(if different than above)City ____________________________ State________ Zip code_________Email _____________________________________________________________Emergency contact:Name _____________________________ Relationship to you______________  Voice  Voice  VoicePhone ______________ TTY _______________ TTY _____________ TTY Home Work CellPreferred format for materials from us?  Large Print  Braille  Other  Audio CD  Email/electronic RIDE APPLICATION PAGE 1
    • II. MOBILITY AID, DISABILITY, AND MEDICAL INFORMATION1. Will you be traveling with a personal care assistant (PCA)?  Yes, at all times  No  Sometimes Note: PCAs are not provided by the MBTA or RIDE contractors, but we will provide space on the vehicle for your PCA.2. Do you use a mobility aid or device?  Yes  No a. If yes, which mobility aids or equipment do you use? (check all that apply) Manual wheelchair Walker Powered scooter Powered wheelchair Cane Guide/White cane Prosthetic device/brace Crutches Oxygen tank Service animal (guide dog, etc.) Describe:______________________ Other, please specify:______________________________________ b. Is your scooter/wheelchair wider than 30”?  Yes No  I don’t know  Not applicable c. Is your scooter/wheelchair longer than 48”?  Yes No  I don’t know  Not applicable d. Is the combined weight of you & your mobility device more than 650 lbs?  Yes No  I don’t know  Not applicable 3. Are you currently receiving a treatment/therapy that affects your functional ability to independently use the MBTA fixed route services?  Yes  No If yes, which treatments are you receiving, and for how long? Treatment_______________________Duration__________________________ Treatment_______________________Duration__________________________ RIDE APPLICATION PAGE 2
    • 4. Please identify all conditions that prevent you from independently using MBTA fixed-route services such as buses, trolleys, subway trains (not including commuter rail) some or all of the time.Neuromuscular: Medical: Cardiovascular: Arthritis Cancer Arteriosclerosis Cerebral Palsy Cognitive (D) Asthma Multiple Sclerosis Diabetes Chronic Obstructive Muscular Dystrophy Epilepsy/Seizure Pulmonary Disease Parkinson’s Disease Disorder (C) Congestive Heart Failure Paraplegia Hearing Impairment Cystic Fibrosis Quadriplegia HIV/AIDS Emphysema Stroke/Cerebral Kidney Disease/Dialysis Heart Attack Trauma (Date of Lupus Peripheral Vascular occurrence)________ Mental Health (D) Disease Other:_____________ Surgery (Date)_______ Thrombosis Visual Impairment (B) Other:_______________ Other:_____________A licensed/certified human services or health care provider only needs tocomplete ONE Provider Verification Form: A-General Medical, B-VisualImpairment, C-Epilepsy or Seizure Disorders, D-Cognitive or Mental Healthdisabilities. It is optional to submit additional completed verification forms if youwant to provide more information.5. Is your functional limitation permanent?  Yes  No If No, what is the expected duration? # of Months______ # of Years______ Unsure ______ RIDE APPLICATION PAGE 3
    • III. FUNCTIONAL ABILITIES AND MOBILITY6. Can you, with your mobility device (if applicable):a. Independently ask for and understand written or spoken directions?  Yes  No  Sometimes (Explain)_________________________b. Independently cross the street?  Yes  No  Sometimes (Explain)_________________________c. Independently wait for 10 minutes without a bench or seating area?  Yes  No  Sometimes (Explain)_________________________d. Independently step on and off a sidewalk from a curb?  Yes  No  Sometimes (Explain)_________________________e. Independently board an MBTA bus or subway train if it has a lift/ramp/kneeler? (All buses are 100% accessible.)  Yes  No  Sometimes (Explain)_________________________f. Independently walk up and down a flight of stairs if there is a handrail?  Yes  No  Sometimes (Explain)_________________________g. Independently stand on a moving bus or subway train holding onto a handrail?  Yes  No  Sometimes (Explain)_________________________h. Independently transfer from one bus or subway train to another?  Yes  No  Sometimes (Explain)_________________________i. Independently recognize when it’s time to get on/off the bus/rail vehicle?  Yes  No  Sometimes (Explain)_________________________j. Independently safely travel through crowded and/or complex MBTA facilities?  Yes  No  Sometimes (Explain)_________________________ RIDE APPLICATION PAGE 4
    • 7. How does your disability prevent independent use of the MBTA fixed route services?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. To the best of your knowledge, under optimal conditions, approximately how far can you independently walk/travel outdoors? (with mobility aid if used)  Less than one block  6 blocks (3/4 mile)  1-2 blocks (1/4 mile)  8 blocks (1 mile)  4 blocks (1/2 mile)  I cannot travel alone outdoors Please specify optimal conditions:____________________________________9. What are the barriers in your environment that combined with your disability, prevent you from using the MBTA independently? Some examples may include:  Busy street to cross  Steep hills  Time of day  Lack of curb cuts  No crosswalk light  Snow/Ice  Construction  No sidewalk/Sidewalk condition (Describe): _________________________  Other_________________________________________________________10. Is your condition affected by weather?  Yes  No If yes, please explain:______________________________________________ ________________________________________________________________ RIDE APPLICATION PAGE 5
    • 11. Which of the following best describes your use of MBTA fixed-route services, such as buses and subway trains?  I’ve never used the MBTA  I’ve used the MBTA, but not since the onset of my disability:  0-1 years ago  1-5 years ago  over 5 years ago  I currently use the MBTA system:  Rarely  sometimes/ occasionally  frequently / all the time12. Please explain your experiences/challenges/observations with MBTA fixed- route services? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 13. Have you ever received travel training to use the MBTA fixed route system (bus, trolley, train)?  Yes  No If yes, when?_____________________________________________________ Did you complete the training?  Yes  No 14. If you currently do not use the MBTA fixed-route services, is there anything that might help you to do so? (Check all that apply)  Mobility Device  Route/Schedule Information  Communication Aid  Other_________________________  Orientation & Mobility Instruction or Travel Training 15. Which best describes your current living situation?  Skilled nursing facility  Assisted living facility  Group home  Other:____________  House, apartment  Rehab hospital RIDE APPLICATION PAGE 6
    • 16. Provide any additional information that explains your functional level of mobility or the barriers/conditions that prevent you from using fixed route services. (Attach as much documentation as you need) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ RIDE APPLICATION PAGE 7
    • Sign below to indicate that the information you have given is correct to the bestof your knowledge. If you are unable to sign, you may have someone sign foryou and indicate their relationship to you. I understand that the purpose of this application is to determine if there are times when I cannot use MBTA fixed-routes, such as buses and subway trains, and must therefore use ADA Paratransit services. I certify, to the best of my knowledge, that the information in this application is true and correct. I understand that providing false or misleading information may result in a reevaluation or revocation of my eligibility. X_______________________________ Date ____________ Applicants SignatureSign below to indicate permission for your health provider to releaseinformation for the sole purpose of facilitating your eligibility determination orproviding you with transportation. If you are unable to sign, you may havesomeone sign for you and indicate their relationship to you. I hereby authorize my Human Service or Health Care Provider to release any information necessary to determine RIDE eligibility to the MBTA. X_______________________________ Date ____________ Applicants SignatureApplicant’s Checklist: There is a signature and date in both spaces above. My completed portion of the application, with the appropriate Provider’s Verification Form, has been given to my human service or health care provider. The Provider’s Verification Forms A-General Medical, B-Visual Impairment, C-Epilepsy & Seizure Disorder, and/or D-Mental Health or Cognitive, are complete. NEXT SECTION TO BE COMPLETED BY LICENSED/CERTIFIED STOP HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY RIDE APPLICATION PAGE 8
    • MBTA RIDE GENERAL MEDICAL FORM A THE RIDE PARATRANSIT ELIGIBILITY APPLICATION TO BE COMPLETED BY LICENSED/CERTIFIED HUMAN SERVICE OR HEALTH CARE PROVIDER ONLYBy completing and signing this document, you the health care professional,certify the truth and accuracy of the information provided on this application, tothe best of your professional knowledge. The American with Disabilities Act of1990 requires that the MBTA provide services to persons who are unable to usethe fixed-route system (such as buses, trolleys, subway trains, not includingcommuter rail and boat) due to a disability. The information you provide willallow the MBTA to make an appropriate evaluation of eligibility. To qualify forParatransit service, an individual must meet at least one of the following criteria: Category 1 Individuals who, as a result of a physical or mental impairment (including visual impairments), and without the assistance of another individual (except the operator) cannot board, ride, or disembark from an accessible transit vehicle. Category 2 Individuals who can independently use accessible vehicles, but none are available on their route. Category 3 Individuals who have a specific-impairment related condition that prevents them from independently getting to/from a stop.A licensed/certified human services or health care provider only needs tocomplete ONE Provider Verification Form: A-General Medical, B-VisualImpairment, C-Seizure or Epilepsy Disorders, D-Cognitive or Mental Healthdisabilities. It is optional to submit additional completed verification forms if youwant to provide more information. Information which you provide will assist us in determining the applicantsfunctional ability to use public transportation. It is essential that you be preciseand comprehensive. False or misleading information diverts resources away frompersons legitimately qualified to use this program.
    • THE RIDE Paratransit Eligibility Form A: Licensed Provider’s Form (General Medical)Applicant’s Name:________________________________Date of Birth: _______Applicant’s Address:_________________________________________________Relationship to the applicant: _________________________________________How long have you provided services/treatment for the applicant?___________1. What is the medical condition that prevents applicant from accessing, boarding, disembarking, and/or riding on the MBTA independently? (Note: MBTA fixed-route buses are 100% accessible. Eligibility criteria does not include age, inability to drive or that service would “benefit” the applicant.) ________________________________________________________________2. Date of onset?____________________________________________________3. How does the applicant’s disability in combination with any barriers in the environment, prevent the applicant from independent use of the MBTA fixed route services? ___________________________________________________ ________________________________________________________________4. Does the applicant have the ability to travel in complex, crowded stations? Consider the station, time of day, accessibility of the station, etc.  Yes  No  Sometimes If no or sometimes, please explain: __________________________________ ________________________________________________________________5. Is the applicant’s functional limitation permanent? Yes  No If no, what is the expected duration? # of Months______ # of Years ______ Unsure ______6. For safety reasons, should the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes  No If yes, please explain._________________________________________________________ ________________________________________________________________ MBTA RIDE GENERAL MEDICAL FORM A P1
    • 7. For safety reasons can the applicant be left unattended at pickup or drop-off locations? Yes  No If no, please explain_______________________________________________ ________________________________________________________________8. Do you agree with the applicant’s self assessment on pages 1-7? Yes  No If no, please explain ______________________________________________ ________________________________________________________________ ________________________________________________________________9. Is there any additional information about conditions/barriers that prevent the applicant from using the fixed route some or all of the time ________________________________________________________________10. Provider’s Checklist: I have provided a live signature (not photocopied, or stamped) I have completed all contact info below, including a State Board License # or Certification # ( not NPI, DEA).I certify that the information given above is correct to the best of my knowledge. X______________________________________________________ Signature of Licensed Health Care or Human Service ProviderClearly print your contact info below: CERT # orNAME___________________________________BOARD LIC#_____DATE______PHONE #_________________________________FAX # ____________________BUSINESS ADDRESS _________________________________________________EMAIL ____________________________________________________________When application is fully complete, please mail signed original to:MBTA Office for Transportation Access/ THE RIDETen Park Plaza, Room 5750, Boston, Massachusetts 02116THANK YOU FOR YOUR TIME AND INPUT. MBTA RIDE GENERAL MEDICAL FORM A P2
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    • MBTA RIDE VISION FORM B THE RIDE PARATRANSIT ELIGIBILITY APPLICATION TO BE COMPLETED BY LICENSED/CERTIFIED HUMAN SERVICE OR HEALTH CARE PROVIDER ONLYBy completing and signing this document, you the health care professional, certifythe truth and accuracy of the information provided on this application, to the best ofyour professional knowledge. The American with Disabilities Act of 1990 requiresthat the MBTA provide services to persons who are unable to use the fixed-routesystem (such as buses, trolleys, subway trains, not including commuter rail and boat)due to a disability. The information you provide will allow the MBTA to make anappropriate evaluation of eligibility. To qualify for Paratransit service, an individualmust meet at least one of the following criteria: Category 1 Individuals who, as a result of a physical or mental impairment (including visual impairments), and without the assistance of another individual (except the operator) cannot board, ride, or disembark from an accessible transit vehicle. Category 2 Individuals who can independently use accessible vehicles, but none are available on their route. Category 3 Individuals who have a specific-impairment related condition that prevents them from independently getting to/from a stop.A licensed/certified human services or health care provider only needs to completeONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizureor Epilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional tosubmit additional completed verification forms if you want to provide moreinformation. Information which you provide will assist us in determining the applicants functional ability to use public transportation. It is essential that you be precise and comprehensive. False or misleading information diverts resources away from persons legitimately qualified to use this program.
    • THE RIDE Paratransit Eligibility Form B: Licensed or Certified OMS Provider’s Verification Form (Visual Impairment)Applicant’s Name:______________________________Date of Birth:____________Applicant’s Address: ___________________________________________________Relationship to the applicant:____________________________________________How long have you provided services/treatment for the applicant? _____________1. Please specify the applicant’s Visual Impairment:__________________________2. Date of onset _______________________________________________________3. Is applicant’s functional limitation permanent?  Yes  No If no, what is the expected duration? # of months______ # of years______ unknown______4. What is the prognosis? _______________________________________________5. Please note mobility aids used by applicant:______________________________6. Has the applicant received travel training to use the MBTA fixed route system (buses, trolleys, trains)?  Yes  No  unknown If yes, what were the outcomes? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________7. How does the applicant’s disability, combined with any environmental barriers, prevent independent use of the MBTA fixed route services? (i.e. buses, trolleys, trains) ____________________________________________________________ __________________________________________________________________ __________________________________________________________________8. Please comment on the applicant’s ability to perform the following tasks:• Independently use a mobility aid____________________________________________________________________• Independently cross streets/intersections____________________________________________________________________• Independently travel in various conditions (lighting, weather, background noise)____________________________________________________________________• Independently navigate paths of travel, inclines, uneven terrain____________________________________________________________________ MBTA RIDE VISION FORM B P1
    • • Independently orient oneself to surroundings, and plan or follow a route___________________________________________________________________• Independently detect stations/stops___________________________________________________________________• Independently navigate curbs/steps w/mobility device (if applicable)___________________________________________________________________9. For safety reasons should, the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes  No If yes, please explain _______________________________________________ _________________________________________________________________10. For safety reasons is the applicant able to be left unattended at pickup or drop- off locations? Yes  No If no, please explain _______________________________________________ ________________________________________________________________11. Any additional information about conditions/barriers that prevent the applicant from using the fixed route some or all of the time ______________________ ________________________________________________________________12. Provider’s Checklist: I have provided a live signature (not photocopied, or stamped) I have completed all contact info below, including a State Board License # or Certification # (not NPI, DEA).I certify that the information given above is correct to the best of my knowledge. X____________________________________________________ Signature of Licensed Health Care or Human Service ProviderClearly print your contact info below: CERT # orNAME_____________________________STATE BOARD LIC#______DATE _______PHONE #______________________________FAX # _________________________BUSINESS ADDRESS____________________________________________________EMAIL ______________________________________________________________When application is fully complete, please mail signed original to:MBTA Office for Transportation Access/ THE RIDETen Park Plaza, Room 5750, Boston, Massachusetts 02116 MBTA RIDE VISION FORM B P2
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    • MBTA RIDE EPILEPSY/SEIZURE DISORDER FORM C THE RIDE PARATRANSIT ELIGIBILITY APPLICATION TO BE COMPLETED BY LICENSED/CERTIFIED HUMAN SERVICE OR HEALTH CARE PROVIDER ONLYBy completing and signing this document, you the health care professional, certifythe truth and accuracy of the information provided on this application, to the best ofyour professional knowledge. The American with Disabilities Act of 1990 requiresthat the MBTA provide services to persons who are unable to use the fixed-routesystem (such as buses, trolleys, subway trains, not including commuter rail and boat)due to a disability. The information you provide will allow the MBTA to make anappropriate evaluation of eligibility. To qualify for Paratransit service, an individualmust meet at least one of the following criteria: Category 1 Individuals who, as a result of a physical or mental impairment (including visual impairments), and without the assistance of another individual (except the operator) cannot board, ride, or disembark from an accessible transit vehicle. Category 2 Individuals who can independently use accessible vehicles, but none are available on their route. Category 3 Individuals who have a specific-impairment related condition that prevents them from independently getting to/from a stop.A licensed/certified human services or health care provider only needs to completeONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Epilepsyor Seizure Disorder, D-Cognitive or Mental Health disabilities. It is optional to submitadditional completed verification forms if you want to provide more information. Information which you provide will assist us in determining the applicants functionalability to use public transportation. It is essential that you be precise andcomprehensive. False or misleading information diverts resources away from personslegitimately qualified to use this program.
    • THE RIDE Paratransit Eligibility Form C: Licensed Provider’s Verification Form (Epilepsy or Seizure Disorder)Applicant’s Name:________________________________Date of Birth: ___________Applicant’s Address:_____________________________________________________Relationship to the applicant: _____________________________________________How long have you provided services/treatment for the applicant?_______________ 1. Type of Seizure: ____________________________________________________ 2. Seizure Frequency: __________________________________________________ 3. Does the seizure alter consciousness or awareness?  Yes  No 4. Are the seizures preceded by an aura?  Yes  No 5. Are there any triggers to the seizures?  Yes  No If yes, what are they? _______________________________________________ __________________________________________________________________ 6. What behaviors are exhibited during/following the applicant’s seizure? __________________________________________________________________ __________________________________________________________________ 7. Is the applicant taking prescribed seizure medications that affect functional ability to independently use the MBTA fixed route services (bus, trolley, train)?  Yes  No If yes, please note the effects of the medication. __________________________________________________________________ __________________________________________________________________ 8. Is the applicant’s functional limitation permanent?  Yes  No If no, what is expected duration? # of Months_____ # of Years_____ unknown_____ 9. What advice or limitations on independent travel have you communicated to the applicant?______________________________________________________ __________________________________________________________________ 10. For safety reasons should the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes  No If yes, please explain ________________________________________________ __________________________________________________________________ MBTA RIDE EPILEPSY/SEIZURE FORM C P1
    • 11. For safety reasons can the applicant be left unattended at pickup or drop-off locations? Yes  No If no, please explain_________________________________________________ __________________________________________________________________ 12. Please provide any additional information on the applicant’s ability to travel independently on the MBTA fixed route services._________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 13. Provider’s Checklist: I have provided a live signature (not photocopied, or stamped) I have completed all contact info below including a State Board License # Or Certification # (not NPI, DEA). I certify that the information given above is correct to the best of my knowledge. X____________________________________________________ Signature of Licensed Health Care or Human Service ProviderClearly print your contact info below: CERT # orNAME_______________________________STATE BOARD LIC#________DATE______PHONE #______________________________FAX # ___________________________BUSINESS ADDRESS______________________________________________________EMAIL ________________________________________________________________When application is fully complete, please mail signed original to:MBTA Office for Transportation Access/ THE RIDETen Park Plaza, Room 5750, Boston, Massachusetts 02116 THANK YOU FOR YOUR TIME AND INPUT. MBTA RIDE EPILEPSY/SEIZURE FORM C P2
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    • MBTA RIDE COGN/MH FORM D THE RIDE PARATRANSIT ELIGIBILITY APPLICATION TO BE COMPLETED BY LICENSED/CERTIFIED HUMAN SERVICE OR HEALTH CARE PROVIDER ONLYBy completing and signing this document, you the health care professional, certifythe truth and accuracy of the information provided on this application, to the best ofyour professional knowledge. The American with Disabilities Act of 1990 requiresthat the MBTA provide services to persons who are unable to use the fixed-routesystem (such as buses, trolleys, subway trains, not including commuter rail and boat)due to a disability. The information you provide will allow the MBTA to make anappropriate evaluation of eligibility. To qualify for Paratransit service, an individualmust meet at least one of the following criteria: Category 1 Individuals who, as a result of a physical or mental impairment (including visual impairments), and without the assistance of another individual (except the operator) cannot board, ride, or disembark from an accessible transit vehicle. Category 2 Individuals who can independently use accessible vehicles, but none are available on their route. Category 3 Individuals who have a specific-impairment related condition that prevents them from independently getting to/from a stop.A licensed/certified human services or health care provider only needs to completeONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizure orEpilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional to submitadditional completed verification forms if you want to provide more information. Information which you provide will assist us in determining the applicants functionalability to use public transportation. It is essential that you be precise andcomprehensive. False or misleading information diverts resources away from personslegitimately qualified to use this program.
    • THE RIDE Paratransit Eligibility Form D: Licensed Provider’s Verification Form (Cognitive or Mental Health Conditions)Applicant’s Name: ________________________________ Date of Birth:___________Applicant’s Address: _____________________________________________________Relationship to the applicant:______________________________________________How long have you provided services/treatment for the applicant?________________ 1. What is the applicant’s diagnosis (DSM-IV)? ______________________________ 2. Date of onset? ______________________________________________________ 3. What is the prognosis? _______________________________________________ 4. Is the applicant taking medications related to this disability that affect functional ability to independently use the MBTA fixe route services?  Yes  No a. If yes, please describe the effects of the medication. ___________________________________________________________________ ___________________________________________________________________ 5. Is the applicant receiving treatment/therapy that affect functional ability to independently use the MBTA fixed route services?  Yes  No a. If yes, please specify treatment/therapy and indicate an expected duration. Treatment_________________________Duration__________________________ Treatment_________________________Duration__________________________ 6. Is the applicant’s disability the same every day?  Yes  No a. If no, please explain ________________________________________________ __________________________________________________________________ __________________________________________________________________ 7. Are any of the following affected by the individual’s disability? Check all that apply. _____Orientation _____Concentration _____Monitoring time _____Problem-solving _____Coping Skills _____Judgement _____Short term memory _____Communication _____Gait or balance _____Long term memory _____Consistency _____ Social behavior _____Aggression _____Performance _____Other __________________________________________________________ MBTA RIDE COGN/MH FORM D P1
    • 8. Please explain how the above interferes with safe travel?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. Describe how the applicant’s disability affects his/her ability to independently complete the following travel tasks:• Orient oneself to environment ________________________________________• Travel alone outside _________________________________________________• Leave the house on time _____________________________________________• Seek and act on directions ____________________________________________• Find way to/from bus stop or station ___________________________________• Cross streets _______________________________________________________• Wait for a bus or subway train _________________________________________• Board correct bus or subway train ______________________________________• Ride on a bus or train ________________________________________________• Transfer to a second bus or train or exit at the correct destination __________________________________________________________________• Understand time and follow a schedule__________________________________• Know when he/she is lost_____________________________________________• Get help if he/she is lost______________________________________________• Recognize and avoid dangers __________________________________________10. Please provide information on how the applicant’s disability, combined with any environmental barriers, prevent independent use of the MBTA fixed route services? (bus, trolley, train) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ MBTA RIDE COGN/MH FORM D P2
    • 11. For safety reasons should the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)?  Yes  No If yes, please explain.__________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 12. For safety reasons is the applicant able to be left unattended at pickup or drop-off locations? Yes  No If no, please explain___________________________________________________ ____________________________________________________________________ 13. Is there any other information that would be an indication of the applicant’s inability to independently use fixed-route public transportation? ____________________________________________________________________ ____________________________________________________________________ 14. Provider’s Checklist: I have provided a live signature (not photocopied, or stamped) I have completed all contact info below including a State Board License # or Certification # (not NPI, DEA). I certify that the information given above is correct to the best of my knowledge. X___________________________________________________ Signature of Licensed Health Care or Human Service ProviderClearly print your contact info below: CERT # orNAME_______________________________STATE BOARD LIC#________DATE_______PHONE #______________________________FAX # ____________________________BUSINESS ADDRESS_______________________________________________________EMAIL _________________________________________________________________When application is fully complete, please mail signed original to:MBTA Office for Transportation Access/ THE RIDETen Park Plaza, Room 5750, Boston, Massachusetts 02116THANK YOU FOR YOUR TIME & INPUT. MBTA RIDE COGN/MH FORM D P3