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The METROLift Application form is a critical document for individuals seeking paratransit services in the Houston area. It serves as a comprehensive tool to assess a person's eligibility for METROLift, which is designed for those who cannot utilize the standard METRO bus service due to disabilities. The application spans several pages, requiring detailed personal information, including the applicant's name, address, and contact details. It also delves into individual mobility needs, asking about disabilities, assistive devices used, and the ability to navigate to a bus stop independently. Importantly, pages five and six necessitate certification from a physician or certified health professional, ensuring that medical insights are included in the evaluation process. Applicants are encouraged to provide accurate and thorough responses, as this information directly impacts their eligibility determination. Assistance from family members, caregivers, or representatives is permitted, ensuring that all applicants can complete the form with the necessary support. For any questions, METROLift Customer Service is available to help guide applicants through the process.

Metrolift Application Example

1900 Main

P.O.Box 61429

Houston, TX 77208-1429

Client ID #

Date Entered

Processed by

Application for METROLift Service

Instructions: On pages 1 – 4 of this application, METROLift is asking for information about you and your ability to use METRO bus service. Please take the time to answer ALL questions carefully and completely. A friend, guardian, caregiver, agency service representative or family member may help you complete your portion of the application, pages 1- 4. Accurate information is required about you, your medical impairment, and your functional capacity. Pages 5 - 6 must be completed and certified by a physician/certified health professional who is familiar with your impairment or condition. Both the eligibility form and the doctor's additional signature must be submitted to METROLift for processing. Failure to do so will delay the processing of your application.

If you have questions, please call METROLift Customer Service at 713-225-0119.

Have you ever applied for METROLift?

No

Yes

TO BE COMPLETED BY APPLICANT

 

Name of Applicant

Last/Apellido

 

 

 

First/Nombre

 

 

 

Middle/Inicial Nombre de solicitante

 

 

 

 

 

 

 

 

Nombre de solicitante

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address/Street / Dirección/Calle

 

 

 

Apartment Number

City/Ciudad

 

 

 

 

Zip Code/Codigo Postal

 

 

 

 

 

 

Numero de Apatamento

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth/Fecha de Nacimiento

 

 

Home Phone Number/En Casa Número de Teléfono

 

 

Other Phone/Otro Teléfono

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment Complex Name/Nombre

 

 

 

 

 

 

 

 

 

 

 

 

 

Gate Code/Codigo de Cochera

 

de Apartamentos

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address/Dirección de Envío

 

 

 

 

City/Ciudad

 

 

 

 

State/Estado

 

 

Zip Code/Codigo Postal

 

If different from home address/Si diferente de domicilio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Signature (required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Firma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

Date/Fecha

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Emergency Contact/Contacto de Emergencia

 

Relationship/Relación

Emergency Phone/Numero de Emergencia

Page 1

METRO 0447-17-(06/22)

INDIVIDUAL AND MOBILITY INFORMATION

1.Please state your disability(s).

2.What assistive device(s) do you use when traveling? (Please check all that apply.)

Support Cane

Manual wheelchair

Trained service animal

Crutches

Powered wheelchair

Communications device

Walker

Power scooter

“White cane”

Leg brace(s)

Portable oxygen

None

Other (describe)

 

 

3.What is the nearest street intersection to your home? (Example: Polk & Wayside)

4.Can you walk or use your wheelchair or assistive device(s) from your home to that

intersection without assistance?

 

Yes

 

No

If “no,” please explain.

 

 

 

 

 

5.Can you find your way to a bus stop without getting lost? If "no," please explain.

Yes

No

6. How long can you stand and wait for a bus?

 

 

15 minutes

10 minutes

5 minutes

Less than 5 minutes

7.All buses have a "destination sign" in front, which shows the route name and number.

Can you read a bus destination sign?

Yes

No

Can you ask the driver where the bus is going?

Yes

No

Can you give or write a note to the driver?

Yes

No

Can you understand the driver's answer?

Yes

No

If "no" to any questions, please explain.

 

 

 

 

 

 

 

 

 

 

 

METRO 0447-17-(06/22)

Page 2

8. If you were on the bus, could you pay the fare by putting money in the fare box, or by tapping the

METRO Q Card on the Q box?

.

If “no” please explain

Yes

No

9.If you were on the bus, could you recognize the place where you wanted to get off the bus?

Yes No

If "no," please explain.

10.Please tell us about the times when you can use METRO’s local fixed-route bus service? (Example: if short distance to bus stop; take attendant; need to get somewhere.)

11.Have you ever received " orientation and mobility training "or " travel training?" Yes If " yes," please list any METRO bus routes on which you can travel:

No

12.Please tell us the reasons you feel you cannot use METRO’s local fixed-route bus service for some or all trips.

13.How do you currently travel (self, family, friends, bus, rail, METROLift, etc.)? Please explain.

14. Do you require someone to travel with you?

Yes

If "yes," please explain

 

No

15.Can you wait independently alone at your residence and places to which you travel?

Yes No

If "no," please explain.

METRO 0447-17-(06/22)

Page 3

AGREEMENT AND AUTHORIZATION:

I state that the information I have provided is true and accurate.

I authorize the release of diagnostic and functional information as requested on pages 5 and 6 to METRO for the sole purpose of making a determination regarding my eligibility for paratransit service (METROLift) and understand that personal and medical information will be kept confidential.

I understand that intentionally providing false or misleading information or refusal to undergo an in-person interview assessment is grounds for denial of METROLift services.

If approved, I agree to follow the rules and guidelines established by METROLift and to promptly inform METROLift of any changes in my residence, phone number and, if applicable, my representative's name and phone number; and any significant change in my condition that would affect my level of mobility.

I understand that failure to follow proper procedures or cooperate with METROLift staff, demonstrating illegal or disruptive behavior or, if my condition at any time poses a direct threat to the health or safety of others, such situations may result in either suspension and/or termination of service.

Applicant’s Signature:

Date:

If someone other than the applicant is preparing this form, please provide the following information about the preparer:

Name: (please print) ________________________________________________

Day Phone: ______________________________ Relationship: ______________

Preparer’s Signature: ______________________ Date: ____________________

METRO 0447-17-(06/22)

Page 4

Patient's Name: (please print) ____________________________________________________

Date of Birth: _____________________ Contact No.: _________________________________

Address: ______________________________________________________________________

Dear Physician or Healthcare Professional:

We need your assistance in determining eligibility for services provided by METROLift to persons with disabilities who are unable to use local bus transportation. We are seeking specific information as to what prevents the person from using METRORail and the METRO bus routes that provide transportation throughout the area. METRO buses are equipped with ramps, lifts, and kneeling features to assist boarding as well as automatic announcements of major stops to help riders know where they are along the route. The Americans with Disabilities Act of 1990, 49 CFR 37.121, Subpart F states– “..each public entity operating a fixed route system shall provide paratransit or other special service to individuals with disabilities that is comparable to the level of service provided to individuals without disabilities who use the fixed route system.” “By complementary, DOT means service for individuals with disabilities who cannot use the fixed route bus system.” The information requested of you in the following sections will be used to help determine the applicant’s METROLift eligibility. It is important that all questions be answered completely and accurately to the best of your knowledge and in accordance with your records. If the information is incomplete or unclear, we may need to contact you for clarification. Thank you for your cooperation.

1.

Have you previously seen this patient?

Yes

No

2.

Please rate (Excellent / Good / Fair / Poor / None / Don’t Know) the applicant in terms of:

a. Upper body strength

b. Lower body strength

c.Coordination

d.Balance

e.Self awareness

f.Independent judgment

g.Sense of direction

h.Ability to understand and follow instructions

i.Verbal communication

j.Written communication

k.Stamina and endurance

Excellent Good Fair Poor None Don’t Know

3.In your opinion, can the applicant travel independently from his/her house to the sidewalk?

Yes

No

Sometimes

 

 

 

If "no" or "sometimes," please explain.

 

 

 

 

 

 

 

 

4. Can the applicant walk up and down two steps?

Yes

No

Sometimes

5.Assuming the use of a mobility aid, if applicable, and with no major barriers in his/her path, how far can the applicant independently travel without assistance?

less than 1/4 mile

1/4 mile

1/2 mile

3/4 mile

more than 3/4 mile

Page 5

6.Does the applicant’s disability require him/her to travel with another person who provides personal

assistance? Yes No Sometimes

7.Please provide medical diagnoses in layman’s terms to describe the applicant’s primary impairments or disabling conditions.

8.We are seeking specific information as to what prevents your patient from accessing the local bus and rail system.

9.

Is the condition

Permanent or

Temporary (months)

 

 

10.

If visually impaired, what is the applicant's best corrected acuity?

 

 

(Snellen)? (R)

 

 

(L)

 

 

 

 

 

 

 

 

 

 

 

Field Restriction: (R)

 

 

(L)

 

 

 

Date of Testing:

 

 

 

11.

If cognitively impaired, what is the applicant’s cognitive age, and IQ level?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Is the applicant a wheelchair user?

Yes

 

No

If yes, how often

 

 

 

13.

Does the applicant use other mobility aids?

 

Yes

No If yes, please describe.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN OR HEALTH CARE PROFESSIONAL’S CERTIFICATION :

I certify that the information I have provided herein is a fair representation of this applicant’s medical impairment or condition and is accurate to the best of my knowledge. I understand that the information provided herein will be used for the sole purpose of determining the applicant’s eligibility for paratransit services. I also agree that METROLift may contact me for clarification of any information I have provided and that I will reply in good faith.

Physician’s/Health Professional’s Full Name

Institution/Facility/Agency Name

Street Address

 

 

 

 

 

 

 

 

Suite #

 

 

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

 

Medical/Social Worker’s License Number

 

 

Telephone #

 

 

 

Fax #

 

 

 

Physician’s/Health Professional’s Signature

 

 

 

 

 

 

 

Date

 

 

***Note: Additional signature of physician/healthcare professional on his/her

letterhead or prescription verifying completion of application is required.

Page 6

File Breakdown

Fact Name Description
Application Purpose The METROLift Application form is designed to gather information about an individual's ability to use METRO bus service, which is necessary for determining eligibility for METROLift services.
Assistance Allowed Applicants may receive help from a friend, guardian, caregiver, agency service representative, or family member to complete the application.
Medical Certification Requirement Pages 5-6 of the application must be completed and certified by a physician or certified health professional familiar with the applicant's impairment or condition.
Contact Information For inquiries, applicants can reach METROLift Customer Service at 713-225-0119.
Governing Law The application complies with the Americans with Disabilities Act of 1990, which mandates that public entities provide comparable paratransit services for individuals with disabilities.

Guide to Using Metrolift Application

Completing the METROLift Application form is an important step in determining your eligibility for paratransit services. It is essential to provide accurate and complete information, as this will help ensure that your application is processed efficiently. Below are the steps to fill out the form correctly.

  1. Begin by entering your Client ID # and the Date on the first page.
  2. Indicate whether you have ever applied for METROLift by selecting Yes or No.
  3. Fill in the Name of Applicant section with your last name, first name, and middle initial.
  4. Provide the last four digits of your Social Security Number.
  5. Complete the Address section, including apartment number, city, and zip code.
  6. Enter your Date of Birth.
  7. List your home phone number and any other phone number where you can be reached.
  8. If applicable, include the name of your Apartment Complex and the Gate Code.
  9. Provide a Mailing Address if it is different from your home address.
  10. Sign and date the form where indicated, confirming the accuracy of the information provided.
  11. Fill in the name, relationship, and phone number of your Emergency Contact.
  12. On pages 1-4, answer all questions regarding your disability, assistive devices, and mobility capabilities.
  13. On pages 5-6, ensure that a physician or certified health professional completes and certifies the required sections regarding your medical condition.

After completing the form, it is crucial to review all the information for accuracy before submission. If you have any questions or need assistance, do not hesitate to reach out to METROLift Customer Service at 713-225-0119.

Get Answers on Metrolift Application

What is the purpose of the METROLift Application form?

The METROLift Application form is designed to gather essential information about individuals who may need specialized transportation services due to disabilities. It helps METRO determine eligibility for METROLift service, which is a paratransit option for those who cannot use the regular bus service. Accurate and complete information is crucial for this assessment.

Who can assist me in completing the application?

Applicants can receive help from various individuals when filling out the application. Friends, guardians, caregivers, agency service representatives, or family members may assist in providing the necessary information on pages 1 to 4. This support can be particularly helpful for those who may find it challenging to complete the form independently.

What information is required from a physician or certified health professional?

Pages 5 and 6 of the application must be completed and certified by a physician or a certified health professional. This section requires detailed information about the applicant's medical condition and functional capabilities. The healthcare professional should be familiar with the applicant's impairment to provide accurate assessments that support the eligibility determination.

What happens if I provide false information on the application?

Providing false or misleading information on the METROLift Application can lead to denial of services. It is essential to be truthful and accurate when filling out the form. Additionally, refusal to participate in an in-person interview assessment may also result in denial of eligibility. METRO takes the integrity of the application process seriously to ensure fair access to services.

How does METRO protect my personal and medical information?

METRO is committed to maintaining the confidentiality of personal and medical information provided in the application. The information is used solely for determining eligibility for METROLift services. Applicants can rest assured that their details will not be shared without consent, and measures are in place to protect sensitive data.

What if I have additional questions about the application process?

If you have questions or need assistance while completing the METROLift Application, you can reach out to METROLift Customer Service. They can be contacted at 713-225-0119. The customer service team is available to provide guidance and clarify any uncertainties regarding the application process.

What should I do if my condition changes after submitting the application?

It is crucial to inform METROLift of any changes in your condition, residence, or contact information after submitting the application. Keeping METRO updated ensures that you receive the appropriate level of service and support. If your mobility status changes significantly, it may affect your eligibility and the services provided.

Common mistakes

Filling out the METROLift Application form can be a straightforward process, but there are common mistakes that applicants often make. One significant error is failing to provide complete information. Each question on the form is designed to gather essential details about the applicant's needs and abilities. Omitting answers, especially to questions about disabilities or mobility aids, can lead to delays or even denial of service. It is crucial to answer every question thoroughly to ensure the application is processed smoothly.

Another frequent mistake is not seeking assistance when needed. The form explicitly states that a friend, family member, or caregiver can help complete it. Many applicants may feel hesitant to ask for help, thinking they should fill it out independently. However, enlisting someone who understands the application process can lead to more accurate and comprehensive responses, ultimately improving the chances of approval.

In addition, applicants often overlook the importance of the physician's certification on pages 5 and 6. This section requires a healthcare professional to verify the applicant's condition. Some individuals may forget to include this certification or may not provide it in a timely manner. Without this crucial information, the application cannot be fully evaluated, which can significantly impact eligibility for METROLift services.

Lastly, misunderstanding the eligibility criteria can lead to errors. Applicants sometimes assume they do not qualify based on misconceptions about their disability or mobility limitations. It is vital to read the instructions carefully and consider all aspects of one’s situation. If there are uncertainties, contacting METROLift Customer Service for clarification can help ensure that the application is completed correctly and increases the likelihood of receiving the necessary support.

Documents used along the form

When applying for METROLift services, several other forms and documents may be necessary to complete the application process. These documents help provide a clearer picture of the applicant's needs and eligibility for paratransit services. Below is a list of commonly required documents.

  • Proof of Disability: Documentation from a healthcare provider confirming the applicant's disability status. This may include medical records or a letter from a physician.
  • Identification Documents: A copy of a government-issued ID, such as a driver's license or state ID, to verify the applicant's identity and age.
  • Social Security Documentation: A statement or card showing the last four digits of the applicant's Social Security number, which is often required for verification purposes.
  • Emergency Contact Information: A form providing details about an emergency contact, including their name, relationship to the applicant, and phone number.
  • Medical History Form: A detailed account of the applicant's medical history, including any previous surgeries or ongoing treatments that may affect mobility.
  • Mobility Assessment: A report from a healthcare professional assessing the applicant's mobility capabilities, including the use of assistive devices.
  • Transportation Needs Assessment: A form that outlines the applicant's transportation needs, including frequency and types of trips required.
  • Authorization for Release of Information: A signed document allowing METRO to obtain necessary medical information from healthcare providers to assess eligibility.
  • Proof of Residency: Documentation confirming the applicant's current address, such as a utility bill or lease agreement.
  • Preparer Information Form: If someone other than the applicant fills out the application, this form captures the preparer's name, relationship to the applicant, and contact information.

Gathering these documents can streamline the application process and ensure that all necessary information is available for review. This helps METROLift make informed decisions about eligibility and service provision.

Similar forms

  • Disability Services Application: Similar to the Metrolift Application, this form collects detailed information about an individual’s disability and their ability to utilize specific services. Both require medical verification to assess eligibility.

  • Medicaid Application: Like the Metrolift Application, this document requires personal and medical information to determine eligibility for services. Both applications emphasize the need for accurate information and may involve a physician's input.

  • Social Security Disability Insurance (SSDI) Application: This form also asks for comprehensive personal and medical details to evaluate an applicant's disability status. Both applications rely heavily on medical documentation and verification.

  • Supplemental Nutrition Assistance Program (SNAP) Application: Similar to the Metrolift Application, this form requests personal information and requires documentation to establish eligibility for assistance programs.

  • Housing Assistance Application: This application seeks information about the applicant’s personal circumstances and financial status, akin to the Metrolift Application's focus on mobility and disability-related needs.

  • Veterans Affairs Benefits Application: Both forms require detailed personal and medical information to assess eligibility for benefits. Medical verification plays a crucial role in both applications.

  • Public Transportation Paratransit Application: Like the Metrolift Application, this document gathers information about an applicant’s mobility challenges to determine eligibility for specialized transportation services.

  • State Disability Benefits Application: This application is similar in that it collects personal and medical data to evaluate eligibility for state-sponsored disability benefits, requiring thorough documentation.

  • Child Disability Benefits Application: This form requires information about a child’s disability and functional capabilities, much like the Metrolift Application, which assesses an individual’s mobility challenges.

Dos and Don'ts

When filling out the METROLift Application form, it’s important to ensure that you provide accurate and complete information. Here’s a list of things you should and shouldn’t do to make the process smoother.

  • Do read the instructions carefully before starting the application.
  • Don’t skip any questions. Every detail is crucial for determining your eligibility.
  • Do ask for help from a friend, family member, or caregiver if you need assistance.
  • Don’t provide incomplete information, especially regarding your medical condition and mobility.
  • Do ensure that your physician completes the necessary sections on pages 5 and 6.
  • Don’t forget to sign and date the application before submitting it.
  • Do keep a copy of the completed application for your records.

Following these guidelines can help you submit a thorough application and avoid delays in the review process. Remember, the more accurate and complete your information, the better your chances of receiving the services you need.

Misconceptions

There are several misconceptions about the METROLift Application form that can lead to confusion for applicants. Understanding these misconceptions can help ensure a smoother application process. Below is a list of common misunderstandings:

  • Misconception 1: The application can be filled out without assistance.
  • Many people believe they must complete the application on their own. However, a friend, guardian, or caregiver can help fill out the first four pages, which is encouraged for accuracy.

  • Misconception 2: Only the applicant must provide information.
  • Some think that only the applicant's information is needed. In reality, a physician or certified health professional must complete and certify pages 5 and 6, providing essential details about the applicant's medical condition.

  • Misconception 3: Completing the application guarantees eligibility.
  • Applicants often assume that submitting the form will automatically qualify them for METROLift services. Eligibility is determined based on the information provided, and additional assessments may be required.

  • Misconception 4: The application is only for those with severe disabilities.
  • Some individuals think that only those with severe impairments can apply. However, METROLift serves a wide range of disabilities, and anyone who has difficulty using standard bus services may be eligible.

  • Misconception 5: Providing false information will not have consequences.
  • There is a belief that giving inaccurate information won't affect the application. In fact, providing false or misleading information can lead to denial of services or even suspension of already granted services.

  • Misconception 6: The application process is quick and straightforward.
  • Many applicants expect the process to be simple and quick. However, it can take time to gather all necessary information, especially if a physician's input is required.

  • Misconception 7: Applicants will be informed about their status immediately.
  • Some individuals believe they will receive immediate feedback on their application status. In reality, the review process may take time, and applicants should be prepared for potential delays.

Key takeaways

Here are key takeaways for filling out and using the METROLift Application form:

  • Complete all sections: Ensure every question on pages 1-4 is answered thoroughly. Incomplete information may delay your application.
  • Get help if needed: A friend, family member, or caregiver can assist you in completing the application.
  • Medical certification required: Pages 5-6 must be filled out and signed by a qualified physician or health professional.
  • Be honest: Provide accurate information about your disability and mobility. Misleading information may result in denial of services.
  • Emergency contact: Include a reliable emergency contact and their phone number to ensure safety during travel.
  • Understand the process: If you have questions, reach out to METROLift Customer Service at 713-225-0119 for assistance.
  • Know your rights: The application is designed to ensure that individuals with disabilities receive appropriate transportation services.
  • Follow up: After submitting your application, monitor your status and be prepared for any additional information requests.
  • Review the rules: Familiarize yourself with METROLift's guidelines and responsibilities once you are approved for service.