Humboldt Transit Authority
133 V Street
Eureka, CA 95501

DATE RECEIVED:______________________

Assessment for Transportation
Eligibility Information

ADA Paratransit is transportation for persons, who because of a physical or mental condition are unable to ride public fixed-route transportation, such as Eureka Transit System. In order to be determined eligible under one of the following categories as defined by the U.S. Department of Transportation and the U.S. Department of Justice the following categories will determine your eligibility.

Category 1

Individual cannot independently use accessible fixed route transit due to a disability either some or all of the time.

The first category of eligibility includes those persons who are unable to fully use accessible fixed route bus services. Included in this category is:

"Any individual with a disability who is unable, as a result of a physical or mental impairment (including a vision impairment), without the assistance of another individual (except the operator of a wheelchair lift or vehicle on the system which is readily accessible to and usable by individuals with disabilities." [Section 37.123(e)(1) of the ADA regulations]

This applies to an individual who cannot independently negotiate the fixed route bus system (board, ride or disembark from a bus or train).

Category 2

The fixed route vehicles the passenger needs to use are not accessible and/or the lift cannot be deployed at needed stops.

The second category of eligibility includes:

"Any individual with a disability who needs the assistance of a wheelchair lift or other boarding assistance device and is able, with such assistance, to board, ride and disembark from any vehicle which is readily accessible and usable by individuals with disabilities if the individual wants to travel on a route of the system during hours of operation of the system at a time, or within a reasonable period of such time, when such a vehicle is not being used to provide designated public transportation on the route." [Section 37.123(e)(2) of the ADA regulations] This also applies to any individual who would be able to use the fixed route bus system if an accessible vehicle were available, or for an individual who wants to use a designated station/stop, but the lift cannot be deployed or would be damaged if deployed or temporary conditions render a designated stop unsafe for use by passengers.

Category 3

Individual's specific impairment related condition prevents him/her from getting to or from the fixed route transit system.

The third category of ADA paratransit eligibility includes:

"Any individual with a disability who has a specific impairment-related condition which prevents such individual from traveling to a boarding location or from a disembarking location on such system." [Section 37.123(e)(3) of the ADA regulations]

This applies to an individual who, because of his/her disability, cannot access a bus stop or a rail station to board the fixed route bus system and cannot access his/her final destination after disembarking from a fixed route bus. Eligibility under this category is determined for a specific ride each time the eligible customer calls.

An important qualifier for this category is also included in the regulations:

Environmental conditions and architectural barriers not under the control of the public entity do not, when considered alone, confer eligibility for ADA paratransit service to passenger. (Please note, an inconvenience in using the fixed route bus system is also not a basis for eligibility)

The Humboldt Transit Authority reserves the right to conduct a re-certification process as necessary to keep our records up-to-date. Service will be provided only to persons who have been certified. Qualified Medical Professionals will be asked to assist in making the determination of certification by completing a form describing the applicant’s disability. The final decision as to whether or not the applicant qualifies for Dial-a-Ride will be made by Humboldt Transit Authority.

To help us accurately determine your eligibility for Dial-a-Ride, please fill out the application form as completely and thoroughly as possible. Once you have completed the form the Humboldt Transit Authority will determine if it will be necessary for an in-person interview.

INTERVIEW PROCESS

If we determine that more information is needed to process your application, or that your application is incomplete, we will schedule an in-person interview. If you know that you will need transportation to the interview, please let us know when we schedule your interview. At the time of your interview, we will ask you additional questions about your eligibility so we can further evaluate your travel abilities and limitations.

If you are determined eligible for dial-a-ride for some trips or for all trips, we will provide you with that information in your letter of eligibility. If it is determined that you are able to use fixed route buses for some or all of your trips, we will notify you in writing of the exact reasons for this decision and provide information about how to appeal our decision. This decision will be made within 21 days of the date you complete your in-person interview or assessment. If a decision is not made within 21 days, we will provide you with dial-a-ride until a final decision is made.

Complaints or comments about the system should be reported to Humboldt Transit Authority, Consuelo Espinosa, at 443-0826 for investigation and appropriate action. All information will be confidential. All passengers are expected to comply with vehicle rules, and understand the "HTA No Show Policy". The HTA No Show Policy is provided in this packet on Page 17.

If you believe you may be eligible for paratransit services please contact our paratransit eligibility department at:

(707) 443-0826 ext. 105 for further assistance.














Please Print

Application for ADA Paratransit Services

IMPORTANT INFORMATION FOR APPLICANTS

This packet includes information and forms you need to apply for paratransit eligibility in the Humboldt County Area. As part of the requirements of the Americans with Disabilities Act (ADA), paratransit service is provided by all public transportation systems. This special type of public transportation service is limited to persons who are unable to independently use regular public transit, some or all of the time, due to a disability or health related condition.

In order to use ADA paratransit service, you must be certified as eligible. Eligibility is determined on a case-by-case basis. According to ADA regulations, eligibility is strictly limited to those who have specific limitations that prevent them from using accessible public transportation.

Your application may be approved for full eligibility (unconditional) or on a limited basis for some trips only (conditional eligibility). If you are found to be capable of using regular bus transit for all trips, without the help of another person, you will not be eligible for paratransit.

To apply for eligibility you must fully complete the attached application form and have the professional verification (pages 12-16) completed and signed by a licensed professional. We will review your ability to use accessible public transportation. After reviewing your application, we may need more information. We may need to:

For a copy of this application in other accessible formats
please call:

707-443-0826 x 105

Applicants persons assisting them are encouraged to read the brochures called "Dial-a-Ride Riders Guide"and before completing the attached form. If you need a brochure call the transit agency. It provides more details about ADA paratransit and the criteria eligibility.

Please Print

Your application must be properly completed and it will be processed within 21 days after it has been received. You may be required to be available for a second level assessment. A second level assessment could include a telephone interview with you, medical verification, or an in-person interview.

You will receive notice of your eligibility determination by mail. If you are certified as eligible, you will be eligible to travel throughout the Dial-a-Ride service areas. If you do not agree with the eligibility determination, you have the right to appeal. Information on how to file an appeal will be included with your eligibility notice. If an eligibility determination takes longer than 21 days, you may be given eligibility that allows you to use the paratransit system until a final decision about your eligibility is made. This does not apply if, we are unable to complete the processing of your application, due inactions on your part.

INSTRUCTIONS FOR APPLICANTS

  1. Please PRINT OR TYPE full responses to all of the questions on the application form. Your detailed responses and explanations will help us make an appropriate determination. Be sure to respond to ALL questions or your application will be considered incomplete. Incomplete applications will be returned.
  2. You are not required to attach additional pages or information. However, you may want to send other documents that you think will help us understand your limitations. All information that you supply will be kept strictly confidential.
  3. You must provide SIGNATURES in three places to complete the application:
    • Applicant Certification (Page 9)
    • Notice of Privacy Act (Page 10)
    • Authorization to Release Information for an appropriate medical or rehabilitation professional (Page 11)
  4. You must have the Professional Verification (Pages 12-16) completed and signed by a licensed professional (not the applicant)
  5. Return the completed application to:

Humboldt Transit Authority
133 V Street
Eureka, CA 95501

For help with the application process or to check on the status of your application
Call 707-443-0826, x105.














APPLICATION FOR ADA COMPLEMENTARY PARATRANSIT SERVICE
To qualify for Dial-A-Ride Service, one must meet the following criteria

PLEASE PRINT

Check One: ____ Unable to use public transportation ____ Resident of a convalescent home

Date: _________________________ Emergency Contact No.:___________________________

Name: ___________________________________________________________________________

Birthday: _______________________ Phone:_________________________________

Address: __________________________ City: ______________ State: _____ Zip: ___________

Male_____ Female_____ Email Address (optional):____________________________________

Do you Speak English? Yes or No, I speak____________________________________________

Agency Certifying: _________________________________________________________________

What is your disability/medical diagnosis that prevents you from using Public Transit? *No longer driving is NOT a limitation* ____________________________________________________________________________________ ____________________________________________________________________________________

When do the effects of your condition effect you to get you to your destination? ____________________________________________________________________________________ ____________________________________________________________________________________

How does your condition affect you when you ride public transit in a functional way?

Is this condition temporary? YES      NO
If yes, please list the date you expect the temporary condition will no longer exist: ________________

Does your disability change from time to time due to medical treatments, medications, or other reasons?
YES     NO
If yes, how?

Can you climb three (3) 12-inch steps without assistant?   YES     NO
How many steps can you go up or down? __________

Can you wait outside without support for more than 10 minutes?   YES     NO

If accepted to use Dial-A-Ride, will you require the assistance of an attendant?   YES     NO
If yes, please name the attendant: __________________________________

Mobility Limitations:

Can travel 200 feet without assistance:    YES     NO
Can travel 3-6 blocks without assistance:   YES      NO
Can travel 6-9 blocks without assistance:    YES     NO
Can climb 12-inch steps without assistance:    YES      NO
Can access bus using lift or ramp:    YES      NO
Can wait outside without support for 10 minutes:   YES      NO

If you require the use of mobility aids, please circle all that apply:

Manual Wheelchair   YES      NO
Electric Wheelchair    YES      NO
Electric Scooter    YES      NO
Cane    YES      NO
Walker   YES      NO
Service Animal    YES      NO
Care Worker/Attendant    YES      NO
Oxygen Tank    YES      NO

If you use a manual wheelchair, what type of obstacles could prevent you from using the public transit system that are equipped with a lift or ramps?

____________________________________________________________________________________ ____________________________________________________________________________________

Do you have a communication disability which necessitates the use of some type of communication aid?   YES      NO
If yes, what kind of communication aid do you require?

____________________________________________________________________________________ ____________________________________________________________________________________

Please check the box that best describes your current living situation:
____24 hour care or Skilled Nursing Facility
____Assisted Living Facility
____I receive assistance from someone that comes to my home to help with daily living activities
____I live with family members who help me
____I live independently (without the assistance of another person)

If you Checked manual wheelchair, power wheelchair or power scooter, circle the picture that most looks like your device.

1. Manual Wheelchair that looks most like this: (Circle One)
1 2 3

2. Power Wheelchair that looks most like this: (Circle One)
1 2 3

3. Power Scooter that looks most like this: (Circle One)
1 2 3

SIGNATURE PAGE:

In order for the Humboldt Transit Authority to evaluate your request for eligibility, it may be necessary to contact a health care or rehabilitation professional for additional information about how your disability prevents you from using regular bus service. It is important that you identify one or more qualified professionals who are familiar with your particular disability and how it prevents you from using the bus system. You must include complete telephone and address information including zips codes for all professionals listed.

Qualified professionals include:

Family Physician                  Independent Living Specialist                            Rehabilitation Specialist
Ophthalmologist               Independent Independent Physical Therapist          Registered Nurse
Occupational Therapist          Dialysis Social Worker                                          Social Worker     
Psychologist

(PLEASE PRINT)
Family Physician (or other qualified professional):___________________________________________________ Family Physician (or other qualified professional):___________________________________________________
Professional's agency (if any) Phone#:___________________________________________________ Professional's agency (if any) Phone#:___________________________________________________
Address:___________________________________________________ Address:___________________________________________________
City/State/Zip:___________________________________________________ City/State/Zip:___________________________________________________

CERTIFICATION AND AUTHORIZATION:

I certify that the information provided in this application is true and correct. I understand that falsification of information may result in denial of service. I authorize the professional listed above to release to Humboldt Transit Authority information about my disability and its effect on my ability to travel on the regular bus system. I understand that I may revoke this authorization at any time. Unless earlier revoked, this form will permit the professional listed to release the information described up to 60 days from the date below.

Signature of Applicant:_________________________________Date:____________________
Signature of person assisting applicant:_____________________________________________
Relationship:__________________________________________________________________
Print Name:___________________________________________________________________














Notice of Privacy Practice
Humboldt Transit Authority respects your privacy. We understand that your personal health and eligibility information is very sensitive. We will not disclose your information to anyone outside of the agency unless you in writing, or unless the law authorizes us to do so. Also, we cannot process any eligibility application that does not have authorization signed by you, your representative or legal guardian on all pages where a signature is required. Our privacy practices cover all authorized information contained in your ADA eligibility file.

Use and Disclosure of ADA Eligibility Information

The information contained in your eligibility file includes all applications submitted and any health information received that aids in determining your eligibility. It may also include any letters received on your behalf, documented conversations, trip plans, and other information pertinent to your ADA eligibility and service provision.

The Humboldt Transit Authority uses this information to determine eligibility and for assessing or providing transportation service needs. Staff access to this information is limited to those employees who must review it for the purposes stated above. Conditional and temporary paper applications and eligibility determination information will be kept for 1 year. Unconditional applications will be kept for 5 years and all eligible applicants will be required to submit a new re-certification process. Certifications may be reviewed if someone questions your eligibility determination or may be reviewed in a FTA Compliance Review.

  • You have the right to review your file. Your request must be made in writing or the review may occur in person with valid identification.
  • You may request that a copy of your file be mailed to you. You may be required to pay a fee for this service.












Received and Reviewed:

Please Print Name:______________________________________________________________

Applicant/Patient/Responsible Party Signature________________________________________

Relationship to Applicant/Patient__________________________Date:_____________________












Medical Release Form for Humboldt Transit Authority

In order for Staff to process your transportation application and obtain needed medical information to make eligibility determination, we must ask that you complete and sign this information release form. This release form authorizes the release of medical information that is needed to determine eligibility for door to door services. Failure to complete this form may result in the delay of eligibility determination or the denial of services.

I _________________________________________ authorize Humboldt Transit Authority, to review my personal medical records submitted by a qualified professional. I understand that this information will be used solely for the purpose of determining eligibility for transportation services and will not be shared with any other agencies except where allowed by law. I understand I have the right to revoke this authorization in writing at any time. I understand that failing to provide authorization may result in the denial of transportation services until such time that the information being requested may be obtained.

Received and Reviewed:

Please Print Name:______________________________________________________________

Applicant/Patient/Responsible Party Signature________________________________________

Relationship to Applicant/Patient__________________________Date:_____________________












Please Print












See Next Page for REQUIRED Professional
Verification Form
Pages 13-16















Application for ADA Paratransit Service














PROFESSIONAL MEDICAL VERIFICATION
Page 1 of 4

Letter of Introduction

This letter is to inform you that one of your patients is requesting certification.

The ADA Complementary Paratransit/Dial-a-Ride/Dial-a-Lift Program has been established to serve the needs of persons who are unable to use the existing public transportation services offered by Redwood Transit, Eureka Transit, Arcata & Mad River Transit, and Southern Humboldt Transit.

The agency certifying clients for the ADA Complementary Paratransit/Dial-a-Ride/Dial-a-Lift is the Humboldt Transit Authority. We are asking physicians to assist us in determining patient eligibility. The Humboldt Transit Authority will make the final determination of eligibility.

The word “unable” as it relates to using the transit system means that performing the function is absolutely impossible or causes severe or continuing pain (not discomfort, occasional pain, or difficulty).

ADA Paratransit is transportation for persons, who because of a physical or mental condition are unable to ride public fixed-route transportation such as Eureka Transit System. In order to be determined eligible under one of the following categories as defined by the U.S. Department of Transportation and the U.S. Department of Justice the following categories will determine their eligibility.

Category 1

Individual cannot independently use accessible fixed route transit due to a disability either some or all of the time.

The first category of eligibility includes those persons who are unable to fully use accessible fixed route bus services. Included in this category is:

"Any individual with a disability who is unable, as a result of a physical or mental impairment (including a vision impairment), without the assistance of another individual (except the operator of a wheelchair lift or vehicle on the system which is readily accessible to and usable by individuals with disabilities." [Section 37.123(e)(1) of the ADA regulations]

This applies to an individual who cannot independently negotiate the fixed route bus system (board, ride or disembark from a bus or train).















PROFESSIONAL MEDICAL VERIFICATION
Page 2 of 4

Category 2

The fixed route vehicles the passenger needs to use are not accessible and/or the lift cannot be deployed at needed stops.

The second category of eligibility includes:

"Any individual with a disability who needs the assistance of a wheelchair lift or other boarding assistance device and is able, with such assistance, to board, ride and disembark from any vehicle which is readily accessible and usable by individuals with disabilities if the individual wants to travel on a route of the system during hours of operation of the system at a time, or within a reasonable period of such time, when such a vehicle is not being used to provide designated public transportation on the route." [Section 37.123(e)(2) of the ADA regulations] This also applies to any individual who would be able to use the fixed route bus system if an accessible vehicle were available, or for an individual who wants to use a designated station/stop, but the lift cannot be deployed or would be damaged if deployed or temporary conditions render a designated stop unsafe for use by passengers.

Category 3

Individual's specific impairment related condition prevents him/her from getting to or from the fixed route transit system.

The third category of ADA paratransit eligibility includes:

"Any individual with a disability who has a specific impairment-related condition which prevents such individual from traveling to a boarding location or from a disembarking location on such system." [Section 37.123(e)(3) of the ADA regulations]

This applies to an individual who, because of his/her disability, cannot access a bus stop or a rail station to board the fixed route bus system and cannot access his/her final destination after disembarking from a fixed route bus. Eligibility under this category is determined for a specific ride each time the eligible customer calls.

Eligibility may be granted on a temporary or conditional basis. Please complete the enclosed form so we can determine the eligibility of your patient. Thank you for your assistance in the completion of this certification.

Please send the completed form back to Humboldt Transit Authority, 133" V" Street, Eureka CA 95501.















PROFESSIONAL MEDICAL VERIFICATION
Page 3 of 4

Name of applicant: ________________________________________________________
Birthday: ___________________________________

Circle your answer:

Has the applicant been diagnosed with significant limitations?   YES      NO
If yes, please explain:
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Do the applicant’s abilities change due to medical treatments?    YES      NO
If yes, please explain:
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

What is the maximum distance the applicant can travel unassisted?
Check one:

Less than a 1 block: ____
1-3 blocks: ____
1/4 to 1/2 of a mile: ____
1/2 - 1 mile: ____
1 mile or more: ____

How many large stairs can the applicant climb or descend?
Check one:

1-2 stairs:
3-4 stairs:
5 or more:
Varies:

How many times have you seen your patient walk more than 5 feet?
If variable, please explain:

____________________________________________________________________________________ ____________________________________________________________________________________















PROFESSIONAL MEDICAL VERIFICATION
Page 4 of 4

Without assistance, can the applicant perform the following activities?

Ask for, understand, and follow directions:   YES     NO
Cope with unexpected changes in routine:   YES      NO
Recognize landmarks:    YES      NO
Cross busy streets:    YES    NO

Does the applicant require an attendant to complete a trip?   YES      NO
Does the applicant use a service animal?    YES     NO

How frequently has the applicant be seen by you? _______________________________

Please indicate which combination of the following categories best summarizes the applicants limitations: Check all that apply:

The applicant cannot ride the bus without the assistance of an attendant: ____
The applicant cannot board the bus without a lift or ramp: ____
The applicant cannot travel to and from the bus stop: ____
The applicant is homebound and needs medical transportation only: ____
The applicant is temporary in a skilled nurse facility and
needs medical transportation only: ____

Please describe what method you used to determine the eligibility of your patient?

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
SIGNATURE:____________________________________

Professional Name and Title: ______________________________________________________

Signature: ______________________________________ Date: _________________________

Agency: ______________________________________________________________________

Address: _____________________ City: _____________________ State: _____ Zip: ________

Phone Number: ___________________________________