Fillable Form 59101: MET-PLUS Paratransit Application (City of Billings)

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Form 59101: MET-PLUS Paratransit Application (City of Billings)

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The Form 59101: MET-PLUS Paratransit Application (City of Billings) form is 18 pages long and contains:

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95 check-boxes
133 other fields

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File type: PDF

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City of Billings - MET Transit MET-PLUS

1705 Monad Rd

Billings,

59101

(406)

657-8218

Fax (406)657-8419

WWW.METTRANSIT.COM

MET-PLUS Paratransit Application

1. Eligibility Questionnaire

This form must be completed by the

applicant or someone authorized to sign

on the applicant’s behalf.

2. Professional Verification Form

All applicants must sign the Authorization

for the Release of Information included in

Part 2, page 1. The remainder of the form

must be completed by a professional who

is familiar with the applicant’s condition

and qualified to respond (see right).

3. Submit Both Forms Together

Submit both the Eligibility Application

and the Professional Verification

together. All applications will be

processed within 21 calendar days of

receipt of the completed packet and the

applicant will be notified in writing of

MET’s determination of eligibility.

Avoid Delays in Application Process

•

All

pages for both forms must be

submitt

• Check that all questions have been

answered

• Make sure all needed signatures are

present

• Double check the professional credential

section is complete

An incomplete application will be returned to the

applicant one (1) time with a notice of what is missing.

If it is returned to MET-PLUS Paratransit incomplete a

second time, the applicant will be sent a new blank

application to complete.

List of Qualified Professionals:

• Physician or Psychiatrist

• Physical Therapist

• Physician Assistant

• Licensed Clinical Social Worker (LCSW)(LCPC)

• Occupational Therapist

• Registered Nurse or Nurse Practitioner

• Psychologist

• Certified Orientation and Mobility Specialist

• Speech/Language Pathologist

MET recognizes many professionals work with

clients with disabilities and the list above is not

meant to exclude those professionals. In general,

professionals who have completed a multi-year

degree program and/or are licensed by the State

of Montana will suffice. A primary care physician is

often able to adequately complete this form. You

do not need to visit a specialist.

Follow-Up Information

The eligibility of most applicants can be

determined by the forms submitted to MET

Transit staff. However, there may be cases where

MET contacts the applicant or representative for

more information regarding an applicant’s

disability. This contact may include, but is not

limited to questions and information as follows:

• A conversation about the applicant’s mobility

• Reading a bus schedule to plan out a bus trip

• Setting up Fixed-Route Travel Training

• Requests for further professional evaluation

If follow-up information is necessary, your

application will still be processed within 21

calendar days of receipt. Transportation will

be provided.

MET-PLUS Paratransit

Eligibility Application Page 1

Part 1

Eligibility Application

Complete the entire

application. Incomplete

applications will be returned.

 Check this box if someone other than the applicant is completing this form and provide the following

information

Legal Guardian Information

First Name

Last Name

Middle Initial

Street Address

Apartment #

City

State

Zip Code

Home Phone

( )

Mobile Phone

( )

Relationship to Applicant (Family Member, Case Worker, etc.)

In case of emergency, who should we

contact?

Who is authorized to contact MET on your

behalf?

Emergency Contact Name

Contact Name 1 (Individual or Organization)

Primary Phone

( )

Phone

( )

Secondary Phone

( )

Contact Name 2 (Individual or Organization)

Relationship

Phone

( )

Is this a new application, or a recertification?  New  Recertification

Applicant Information

First Name

Last Name

Middle Initial

Street Address

Apt. #

City

State

Zip Code

Is this an apartment complex, mobile home park, or facility?

 Yes  No

Name of complex or facility

Home Phone

( )

Mobile Phone

( )

Sex

 Male  Female

Date of Birth (mm/dd/yyyy)

Primary Language

 English  Other ___________________________

App Received:_________

Approved:____________

Certification:________

MET-PLUS Paratransit

Eligibility Application Page 2

General Information

How long would you like to use the service?  Temporarily  Permanently (Recertification is required

every 2 years)

What is your current primary transportation option?

 Walking  Taxi

 Drive myself  Fixed Route Bus

 MET-PLUS Paratransit

 Other, specify: _____________________

 Ride with somebody  Bicycle

Can you use the fixed route bus without someone else’s help?

 Yes, I currently ride the Fixed Route Buses  No, I have never ridden.

 I only ride with assistance from others.  I do not ride anymore because:__________

 I only ride when the bus stops are accessible.

MET Transit provides free, in-person training to help you learn to ride our Fixed Route

Buses. Would you be interested in this service?

 No  Yes  Possibly, please contact me.

Do you require a Personal Care Attendant to travel with you?

 No  Yes  Sometimes, specify:______________________________________________

Do you travel with a Service Animal?  No  Yes, Type: ______________________________

Mobility Information and Capabilities

What mobility device(s) will you be using? (Note: Larger mobility devices and devices that exceed

600 pounds when occupied may exceed equipment transport capacity.)

 Cane  White Cane  Manual Wheelchair

 Crutches  Prosthesis  Powered Wheelchair or Scooter

 Walker  Portable Oxygen  No aid required

What is your estimated bodyweight? lbs.

MET-PLUS Paratransit

Eligibility Application Page 3

Are you able to complete the following tasks without assistance from another person?

Check a box for each question. If you answer sometimes for any questions please explain.

A. Get to/from a bus stop?

 Always

 Never

 Sometimes

B. Walk or travel using a mobility device for 3 blocks?

 Always

 Never

 Sometimes

C. Get on/off a fixed route bus without using the lift or ramp?

 Always

 Never

 Sometimes

D. Get on/off a fixed route bus using the lift or ramp?

 Always

 Never

 Sometimes

E. Climb three 10-inch steps?

 Always

 Never

 Sometimes

F. Wait at a bus stop while standing for 15 minutes?

 Always

 Never

 Sometimes

G. Wait at a bus stop while sitting for 15 minutes?

 Always

 Never

 Sometimes

H. Maintain your balance entering, exiting, and riding a fixed route bus?

 Always

 Never

 Sometimes

I. Understand and follow verbal directions?

 Always

 Never

 Sometimes

J. Recognize correct stops and landmarks to complete a trip?

 Always

 Never

 Sometimes

K. Hear stops announced by the operator or onboard speakers?

 Always

 Never

 Sometimes

L. Read and follow informational signs?

 Always

 Never

 Sometimes

M. Plan a trip using a bus schedule?

 Always

 Never

 Sometimes

N. Clearly communicate information about yourself?

 Always

 Never

 Sometimes

Please explain any boxes checked Sometimes: _______________________________________

______________________________________________________________________________

Disability Information

These questions help describe your disability and how it may impact you.

What is your disability? __________________________________________________________

______________________________________________________________________________

Is your disability:

 Permanent  Stable  Progressive  Temporary, how long? Months_______Years______

MET-PLUS Paratransit

Eligibility Application Page 4

Explain how your disability prevents you from the following:

Please provide a complete and specific answer. Attach an additional page if needed.

 Getting on or off a lift/ramp equipped Fixed Route Bus; and/or

 Getting to or from a bus stop; and/or

 Successfully completing a bus trip

______________________________________________________________________________

How far can you travel on level ground? (With your mobility aid, if any.)

 Less than one block  Two blocks  Three blocks  Four blocks or more

Can you, with a mobility aid if needed:

 Yes No

Move yourself from your threshold/door to the street curb?

Wait

at the street curb for a ride?

Wait at the front door/lobby for your ride?

 Yes No

(Note: MET Transit operators are not allowed to cross the outer threshold/door of any

residence, facility or business.)

Does your disability prevent you from using Fixed Route service seasonally?

 No, my inability to ride is not weather related.

 Yes, I can only ride Fixed Route Buses in the summer.

 Yes, I can only ride Fixed Route Buses in the winter.

Does your disability change daily in ways that could disrupt your ability to use Fixed Route

Bus service?

 No  Yes, please explain: _____________________________________________________

_____________________________________________________________________________

Mountain Line Paratransit

Eligibility Application Page 5

Please list three trips you frequently take:

Starting Address Ending Address

1. ________________________________ ___________________________________

2. ________________________________ ___________________________________

3. ________________________________ ___________________________________

Application Signature

I understand the purpose of this application is to determine if the applicant is eligible to

use MET-PLUS ADA Paratransit Service. I certify the information provided in this

application is true and correct. I understand that falsification of information could

result in the denial of ADA Paratransit services as well as a penalty under local,

state and federal law. I agree to notify MET-Transit if my circumstances change and I

no longer need to use ADA Paratransit Services. I understand that I am responsible for

authorizing a Professional Verification of my condition(s). I also understand that a

follow-up conversation, an informational meeting or further assessment by a

professional may be requested.

Applicant or Guardian Signature: ___________________________________

Date: ______________________

Part

Completed.

The following pages must be sent to your Health

Care Provider after you complete section 2, page 1,

Information Release.

click to sign

signature

click to edit

MET-PLUS Paratransit

Professional Verification Page 1

Part 2

Professional Verification

Complete the entire

application. Incomplete

applications will be returned.

Information Release

Medical Information / HIPPA Authorization

I, __________________________________ authorize the healthcare provider (listed below),

and their office completing this application to release to MET Transit any protected health

information about my disability in order to verify my eligibility for Paratransit service. I also

authorize the release of further information should it be needed for this application for a

period of 60 days from the date of my signature on this application unless revoked in writing.

Applicant Signature

Date

Applicant Name (printed)

Date of Birth

Your Health Care Provider

Health Care Provider

Provider

Profession

Address

Phone

Fax

The following pages must be filled out by your

Health Care Provider.

click to sign

signature

click to edit

MET-PLUS Paratransit

Professional Verification Page 2

Dear Healthcare Professional:

The patient listed on the accompanying release form is applying for MET

Transit MET-PLUS Paratransit Service. The information you provide in answering

the questions on the enclosed questionnaire will aid MET in making a

Paratransit eligibility determination. Please keep in mind this document is

time sensitive. Because demand for this service is high, qualification criteria

are stringent. For the benefit of the applicant, please answer all of the

questions completely and accurately. Please return completed questionnaires

to the applicant so the applicant can return the completed packet to MET.

In accordance with Americans with Disabilities Act (ADA) guidelines, Paratransit

service is available only for persons who have disabilities that prevent them from

traveling on Fixed Route Buses. The individual could be prevented by inabilities

to independently get to and from a bus stop, on or off a bus, or to successfully

navigate to a destination.

Please keep in mind ADA Paratransit eligibility is not based on age, a medical

condition, the inability to drive, or the use of a particular mobility aid. The

severity of a disability does not confer eligibility. Comfort and convenience are

not factors. ADA Paratransit eligibility is based on the EFFECT a disability has

on the client's ability to use the regular MET Transit lift and ramp

equipped Fixed Route Bus system.

All information provided will remain confidential. If you have any questions,

please call (406)657-8218.

Thank you for your assistance,

MET Transit MET-PLUS Paratransit Services

City of Billings - MET Transit MET-PLUS

1705 Monad Rd

Billings,

59101

(406)

657-8221

Fax (406)657-8419

WWW.METTRANSIT.COM

MET-PLUS Paratransit

Professional Verification Page 3

General Disability Questions

Describe the diagnosed disability or disabilities you are currently treating this individual for:

______________________________________________________________________________

Check all that apply

Is the patient’s disability:

 Permanent  Stable  Progressive  Temporary - How long? Months_____Years____

Does your client’s disability:

 Affect mobility  Affect judgment  Require use of a mobility aid

 Require them to have assistance when traveling outside their residence

Can your client:

A. Walk two blocks (600 feet) with their mobility aid?  Yes  No

B. Climb three standard steps without assistance? Yes  No

C. Stand without support for 15 minutes?  Yes  No

D. Walk or stand without debilitating pain or discomfort?  Yes  No

E. Board or de-board a fixed route bus equipped with a lift or ramp?  Yes  No

F. Recognize correct stops and landmarks to complete a trip?  Yes No

G. Hear and understand verbal information?  Yes  No

H. Read and understand informational signs?  Yes No

I. Plan a trip using public transportation?  Yes  No

J. Communicate information about themselves? Yes  No

(checking this box means the client cannot travel safely without a PCA)

MET-PLUS Paratransit

Professional Verification Page 4

Disability Specific Questions

Please only complete those questions that apply to the applicant for this section.

Does the applicant experience seizures?  No  Yes

Is the applicant’s judgment impaired?  No  Yes

Does this condition affect the applicant’s ability to move independently outside

their residence or a supervised environment?  No  Yes

Does the applicant experience any hallucinations, delusions, or disassociation?  No  Yes

Does this prevent the applicant from being oriented to person, place, & time?  No  Yes

Please

describ

any

triggers

tha

may

ause

psy

cholo

gic

disorders

manif

est

_________________________________________________________________________

Please describe the functional limitations caused by this impairment.

______________________________________________________________________________

MET-PLUS Paratransit

Professional Verification Page 5

Mobility and Safety Questions

Does the applicant have a visual impairment that affects their ability to move about in the

environment?

 No  Yes If yes, please explain: _____________________________________________

______________________________________________________________________________

Has the applicant received any orientation & mobility training?

 No  Yes If yes, please explain: _____________________________________________

______________________________________________________________________________

Please list any side effects of medication the applicant experiences that could affect

transporting them safely. ________________________________________________________

______________________________________________________________________________

Would you like to add any additional comments on the functional ability of the applicant?

______________________________________________________________________________

MET-PLUS Paratransit

Professional Verification Page 6

Provider Affirmation

Provider Information

Address

Phone

Fax

City

State

Zip code

Provider UPIN # or Tax ID

Employer / Agency

Provider Signature and Affirmation

I am a licensed medical provider or qualified service provider and certify that the above

mentioned individual has the disability and limitations indicated above.

______________________________________________ ______________________

Provider Signature Date

_________________________________________________________

Provider Name (printed)

Part

Completed.

MET-PLUS Paratransit

Professional Verification Page 7

Part 3

Submit Both Forms Together

Complete the entire

application. Incomplete

applications will be returned.

Make sure all questions have been answered, and required signatures are in place.

Submit both the Eligibility Application and the Professional Verification Form.

Mail to:

MET Transit MET-PLUS

1705 Monad Rd.

Billings, MT 59101

Fax #:(406)657-8419

metplus@billingsmt.gov

You may also submit all forms in person at the address above, M-F, 8:00 am – 5:00 pm

or email the forms to metplus@billingsmt.gov

All applications will be processed within 21 calendar days of receipt of a completed packet

and the applicants will be notified in writing of MET Transit’s determination of eligibility.

Follow-Up Information

You will be contacted if follow-up information is required. If so, your application will still be

processed within 21 calendar days of receipt. Transportation will be provided.

Thank you for completing the MET-PLUS Paratransit Application. Please make sure all

questions have been answered, signatures gathered, and both forms are included in your

submission. We look forward to serving you.

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Form 59101: MET-PLUS Paratransit Application (City of Billings)

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Completed 5 March 2021

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