The Metrolift Application form is a crucial document designed for individuals seeking METROLift services, a transportation option for those unable to use standard bus services due to disabilities. This form requires detailed information about the applicant's mobility challenges and medical conditions, which are essential for determining eligibility. To begin the application process, please fill out the form by clicking the button below.
The METROLift Application form is an essential document designed to assess an individual's eligibility for METROLift services, which provide vital transportation options for those with disabilities. This comprehensive form spans several pages and requests detailed information regarding the applicant's personal details, medical impairments, and functional capabilities. The first four pages focus on gathering information about the applicant's ability to use METRO bus services, including their mobility, assistive devices, and any necessary support. It is crucial to answer all questions thoroughly, as incomplete submissions may delay the processing of the application. Pages five and six require certification from a qualified physician or health professional who can attest to the applicant's condition. This ensures that the information provided is accurate and reflects the individual's current mobility status. If assistance is needed while completing the form, applicants are encouraged to seek help from family members, caregivers, or service representatives. For any questions or clarifications, METROLift Customer Service is readily available to provide guidance and support.
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
State/Estado
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?
If “no,” please explain.
5.Can you find your way to a bus stop without getting lost? If "no," please explain.
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?
Can you ask the driver where the bus is going?
Can you give or write a note to the driver?
Can you understand the driver's answer?
If "no" to any questions, please explain.
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
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:
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?
If "yes," please explain
15.Can you wait independently alone at your residence and places to which you travel?
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: ____________________
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?
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?
Sometimes
If "no" or "sometimes," please explain.
4. Can the applicant walk up and down two steps?
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)
Date of Testing:
11.
If cognitively impaired, what is the applicant’s cognitive age, and IQ level?
12.
Is the applicant a wheelchair user?
If yes, how often
13.
Does the applicant use other mobility aids?
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
Filling out the METROLift Application form is an important step in seeking transportation services. It requires careful attention to detail to ensure that all necessary information is provided. Once you complete the form, it will be reviewed to determine your eligibility for METROLift services.
What is the purpose of the METROLift Application form?
The METROLift Application form is designed to gather essential information about an individual's ability to use METRO bus services. It assesses the applicant's disability, mobility challenges, and functional capacity. This information is crucial for determining eligibility for METROLift services, which are provided to individuals who cannot use the local fixed-route bus system due to their disabilities.
Who can assist me in completing the application?
Applicants are encouraged to seek help from a friend, guardian, caregiver, agency service representative, or family member when filling out the application. This assistance can be invaluable in ensuring that all questions are answered accurately and completely, which is necessary for a proper assessment of eligibility.
What information is required from my physician or healthcare professional?
Pages 5 and 6 of the application must be completed and certified by a physician or certified health professional who is familiar with the applicant's impairment or condition. This includes specific details about the applicant's mobility capabilities and any factors that prevent them from using the METRO bus or rail services. Accurate and comprehensive responses from the healthcare provider are vital for determining eligibility.
What happens if I do not provide complete information?
Providing incomplete or unclear information may delay the application process. In some cases, METROLift may need to reach out for clarification. It is important to ensure that all sections of the application are filled out thoroughly to avoid unnecessary delays in determining eligibility for services.
Can I submit the application online?
The METROLift Application form is typically a paper-based document that must be filled out and submitted by mail. Applicants should ensure that they send the completed form to the specified address: 1900 Main, P.O. Box 61429, Houston, TX 77208-1429. For any specific inquiries about the submission process, contacting METROLift Customer Service at 713-225-0119 is recommended.
What should I do if my circumstances change after applying?
If an applicant's circumstances change, such as a change in residence, phone number, or significant changes in their condition affecting mobility, they are required to promptly inform METROLift. Keeping METROLift updated ensures that services remain appropriate and effective for the individual's needs.
Filling out the METROLift Application form can seem straightforward, but many people make common mistakes that can delay the process. Understanding these pitfalls can help ensure a smoother application experience.
One frequent mistake is not providing complete information. Applicants often skip questions or leave sections blank, thinking some details aren’t important. However, every piece of information helps determine eligibility. It’s crucial to answer all questions thoroughly, even if they seem minor.
Another common error is failing to include accurate contact information. Providing the wrong phone number or address can create significant issues. METROLift needs to reach applicants for follow-up questions or to inform them about their application status. Double-checking this information can save time and frustration.
Some applicants neglect to have their physician complete the required sections. Pages 5 and 6 must be certified by a healthcare professional who understands the applicant's condition. Without this certification, the application cannot be processed. It’s essential to coordinate with a doctor to ensure these pages are filled out correctly.
Additionally, people sometimes misunderstand the questions regarding their mobility capabilities. For instance, stating “yes” or “no” without providing explanations can lead to confusion. If someone can walk but only for a short distance, this nuance is important. Clear explanations help METROLift assess individual needs accurately.
Another mistake is not keeping a copy of the application. Applicants often forget to make a copy before submitting it. Having a record of what was submitted can be invaluable for future reference or if any issues arise during processing.
Some individuals also overlook the importance of signatures. Missing signatures can halt the application process. Both the applicant and the preparer (if applicable) must sign the form. This step is crucial for verifying the information provided.
Lastly, applicants may fail to follow up after submitting the application. It’s a good practice to check in with METROLift if no response is received within a reasonable timeframe. This proactive approach can help identify any issues early on and ensure that the application is being processed.
By being aware of these common mistakes, applicants can navigate the METROLift Application process more effectively. Taking the time to fill out the form carefully can lead to a quicker determination of eligibility and access to essential transportation services.
The METROLift Application form is a crucial document for individuals seeking paratransit services. Alongside this application, several additional forms and documents are often required to ensure a comprehensive evaluation of eligibility. Below is a list of these documents, each serving a specific purpose in the application process.
Collectively, these documents help create a comprehensive profile of the applicant's needs and circumstances. They play a vital role in ensuring that individuals receive the appropriate services to support their mobility and independence.
When filling out the METROLift Application form, keep these important guidelines in mind:
Here are some things to avoid:
Misconception 1: The application can be filled out quickly without careful consideration.
Many people believe that the METROLift application can be completed in a hurry. However, this is not the case. The application requires detailed information about your disability and ability to use public transportation. It’s essential to answer all questions thoroughly. Incomplete or inaccurate information can lead to delays or even denial of services.
Misconception 2: A physician's signature is optional.
Some applicants think that having a physician or certified health professional sign the application is not necessary. In reality, pages 5 and 6 must be completed and certified by a qualified medical professional. This step is crucial for verifying your condition and eligibility for METROLift services.
Misconception 3: Assistance from family or friends is not allowed.
There's a common belief that applicants must fill out the form entirely on their own. In fact, friends, family members, or caregivers can assist you in completing the application. Their support can ensure that all relevant information is included, making the process smoother.
Misconception 4: The application process is the same for everyone.
Many assume that the application process is uniform for all applicants. However, each individual's situation is unique, and the application may require different information based on your specific needs. Personal circumstances, such as the type of disability or the use of assistive devices, will influence the details you need to provide.
Key Takeaways for Filling Out the METROLift Application Form