Fillable People with Disabilities (Metropolitan Transportation Authority)

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People with Disabilities (Metropolitan Transportation Authority)

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Metropolitan Transportation Authority
Attention: Reduced-Fare Program
130 Livingston Street
Brooklyn, New York 11201-9625
For further information or additional copies of this Application or the
Application for Senior Citizens, call: 718-330-1234
If you are deaf or hard of hearing, use the free 711 relay or your
preferred relay service provider to contact us. Or visit mta.info
Allow two to eight weeks for processing.
Disk #
Image #
Examiner’s
Signature
Mail
Completed
Application to:
For Office
Use Only
First Name
M.I.
Last Name
Male
Code
Female
City
Home Telephone
Zip Code
Apt. No.
State
Street Address
Social Security Number (optional)
Birth Date
Information Type or print in ink.
2"
1 1/2"
Application for MTA Reduced-Fare MetroCard for
People with Disabilities
ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL
405_16_RF Dis
The Metropolitan Transportation Authority’s (MTA) Reduced-Fare MetroCard
Program for People with Disabilities provides reduced-fare transportation for
persons with the following disabilities:
• receiving Medicare benefits for any reason other than age*
• serious mental illness (SMI) and receiving Supplemental
Security Income (SSI) benefits
• blindness
• hearing impairment
• ambulatory disability
• loss of both hands
• intellectual disability and/or other organic mental capacity impairment
If you do not have one of these disabilities, you are not eligible for the
Reduced-Fare MetroCard Program. Read the entire form carefully before
you apply.
All applicants must sign the affirmation in Section 1 and have the statement and
signature confirmed by a notary public.
All applicants must supply at their own expense one 2" x 1 1/2" photograph
(passport type) with this application. Print your name on the back of your
photograph and attach it where indicated on the front page of this application.
Each applicant must complete the section that applies to their eligibility
category. If the Certification Section applies to your disability, you must have a
physician or other licensed health care provider ("Certifier") complete the
Certification (Section 5). You are responsible for any fee that your Certifier may
charge you.
The MTA may ask for additional proof of disability and may accept or reject
documentation you offer in place of the Certification. In its discretion, the MTA may
waive application requirement(s) on a case-by-case basis. The MTA may require
that the applicant be examined by its own physician at MTA’s own expense.
*If you receive Medicare benefits based on age 65 years or older,
use the Application for Senior Citizens.
If the MTA determines that you are eligible for reduced-fare transportation,
you will receive a Reduced-Fare MetroCard. You are certified for the Reduced-Fare
MetroCard for four years from the date it is issued. (The temporary card can be
used up to one year.) The card itself expires on the date printed in the upper-left
corner of the card and will be renewed automatically.
The Reduced-Fare MetroCard is valid only if you are disabled as stated in your
application. The Reduced-Fare MetroCard can be used only by the person to
whom it is issued and only in accordance with the program guidelines.
If at any time you are no longer disabled as described, your eligibility for the Reduced-
Fare MetroCard Program automatically ceases; you are no longer permitted to use the
Reduced-Fare MetroCard, and you must return the card to the MTA.
Any violation of these Conditions of Use may result in a permanent
revocation of your eligibility for the Reduced Fare Program.
Information
For All
Applicants
2
Conditions of Use
If the application is completed by a personal representative of the applicant for
reduced fare, the personal representative must complete the following:
Print Name of Personal Representative:
Address:
Tel. No.(s):
Relationship to Applicant:(e.g., parent, guardian, attorney, friend, etc.)
I have read and understand all the program information, instructions, and
conditions of use contained in this application. I affirm under penalty of perjury
that all statements made by me on this application and to any Certifier (physician
or other licensed professional) who is named in this application, including all
statements, if any, concerning my disabilities, are true and complete. I understand
that the MTA will rely on the statements made by me and by any Certifier named in
this application to determine my eligibility for the Reduced-Fare Program, that all
such statements may be subject to investigation and verification, and that a material
misstatement or fraud will disqualify me for reduced-fare privileges. I understand
that the MTA may discontinue or change its Reduced-Fare Program without notice.
If the MTA determines that I have not followed the Reduced-Fare Program
Conditions of Use, I understand that my Reduced-Fare MetroCard will be cancelled,
and I will not be eligible to reapply for the Reduced-Fare Program. I understand
that it is a crime to allow anyone else to use my Reduced-Fare MetroCard or for
me to continue to use the card if I am no longer disabled as defined by the
Reduced-Fare Program.
Signature of Applicant or Personal Representative named above: Date:
State of )
) ss:
County of )
On this _____ day of ___________________20__ before me appeared
to me known and known to me to be [check the one that applies]
q the person who is described in and executed the foregoing instrument
q the personal representative of the applicant named above and who executed
the foregoing instrument on behalf of the applicant
and (s)he duly acknowledged to me that (s)he executed the same and that the
statements therein are true.
Signature and stamp of officer:
NOTARY PUBLIC
Information for
All Personal
Representatives
Section 1
Disability Affirmation
Must be completed
by all applicants and
notarized
(See Notary Section
below)
Notary Public
Must be completed
for all applicants,
except when
applying in person,
with photo ID
3
q I am a recipient of Medicare. I have completed
Section 1. Attached to this application is my photograph
and a copy of my Medicare Card.
(Check the box and submit the required information)
If you receive Medicare benefits based on age 65 years or older,
use the application for Senior Citizens.
q I currently receive Supplemental Security Income (SSI) benefits from the United
States Social Security Administration (SSA) and have a serious mental illness.
I understand that I am eligible to receive the MTA Reduced-Fare MetroCard
only while I am receiving SSI. In the event that my SSI eligibility status
changes, I agree to immediately notify MTA.
I authorize the release to MTA and its authorized designee of any records
or information maintained by the SSA in its SSI Record system relevant to
a determination that I am eligible to receive SSI due to a serious mental
illness. This authorization is effective as follows: (1) for so long as the MTA is
reviewing my application for benefits under the MTA Reduced-Fare Program;
and/or (2) to determine my continued eligibility for SSI during the four-year
period commencing on the date the Reduced-Fare MetroCard is issued.
I understand that, if SSA cannot confirm that my records indicate that I
receive SSI and have a serious mental illness, MTA will notify me and require
that I submit a certification confirming my disability from a psychiatrist or other
licensed mental health care provider (Certifier), and that a determination of my
eligibility for Reduced Fare will be delayed until the Certification is submitted
to and reviewed by MTA. In addition, MTA may contact my health care
provider directly, as follows:
Health Care Provider Name:
Address:
Tel. No.:
Signature of Applicant or Personal Representative Date:
Applicant’s Social Security Number:
(Required for SSI Verification)
SECTION 2
To be completed
only by applicants
with Medicare
SECTION 3
To be completed
only by persons with
SSI whose disability
is serious mental
illness (SMI)
Read, check the
box, provide
the information
requested, and
sign and date
where indicated
4
Code
Social Security Number
My application for reduced fare is based on one or more of the following
disabilities (check all that apply):
q blindness — If your eligibility is based on “Blindness” as defined in the Physician’s
Section and you are registered with the New York State Commission for the Blind
and Visually Handicapped, you DO NOT need to have a physician complete
Section 5. However you must submit a copy of your N.Y.S.C.B.V.H. Registration.
q hearing impairment
q ambulatory disability
q loss of both hands
q intellectual disability or other mental capacity impairment
q I have completed and signed the Authorization to Disclose My Health Information
(attached to this application) for release/disclosure of information by my Certifier.
A copy has been provided to my certifier.
Complete the following if applicable:
q I use a service animal to travel. If checked, indicate the type of service animal
(e.g., guide dog)  
q My service animal provides the following assistance.
q My certifier has completed the Certification in Section 5.
CERTIFICATION
Type or print in ink and sign on page 6
Physician/Certifier:
Name (Last) (First) (M.I.)
Office Address Suite No.
City State Zip
Best time to call
Telephone ( )
State Professional License No.
I have examined the applicant (fully identified in the Applicant’s Section of this
application) and signed the back of his/her photograph and attached it to this
application. It is my professional opinion that he/she is a "disabled person" within the
meaning of the term set forth in this document, as follows:
Check all that apply:
q Blindness – There is central visual acuity of 20/200 or less in both eyes with the
use of correcting lenses. Each eye which, accompanied by limitation in the field
of vision such that the widest diameter of the visual field subtends an angle of
greater than 20 degrees, shall be considered as having central visual acuity of
20/200 or less.
Diagnosis:
5
SECTION 4A
To be completed
by all applicants
not covered by
section 2 or 3
SECTION 4B
SECTION 5
Only for applicants
who are eligible
under section
4A or 4B
To be completed
by a physician or
other appropriate
licensed Health Care
Provider (“Certifier”)
q Hearing Impairment – With hearing aids, hearing in each ear is NOT restored to one of
the following minimum levels:
q Average hearing threshold sensitivity for air conduction of 90 decibels or greater, and
for bone conduction to corresponding maximum levels, determined by the simple
average of hearing threshold levels at 500, 1,000 and 2,000 HZ; or
q Speech discrimination scores of 40% or less in each ear.
Diagnosis:
q Ambulatory Disability/Disorder of Gait
From whatever cause, the applicant is unable to move about without a walker,
wheelchair, wheelchair stroller, crutch(es), cane or other mobility/ambulation aid at all
times. The word "unable" is used in its literal sense. The fact that one of these
mechanical aids facilitates movement is not sufficient.
The applicant is unable to move about without use of the following aid:
q Wheelchair q Wheelchair Stroller q Cane q Crutch(es)
q Walker q Other ambulation aid (describe)
Diagnosis:
q Loss of Both Hands – By reason of amputation or anatomical deformity, the person
lacks both hands.
q Intellectual disability and/or Other Organic Mental Capacity Impairment [The
opinion must be given by a physician, medical social worker, or intellectual
disability service agency.] The scores specified below refer to those obtained on the
W.A.I.S., and are used only for reference purposes. Scores obtained on other
standardized individually administered tests are acceptable, but the numerical values
obtained must indicate a similar level of intellectual functioning:
q The person is mentally incapacitated such that he or she is dependent upon others
for personal needs (e.g., toileting, eating, dressing, or bathing) AND is unable to
follow directions, such that the use of standardized measures of intellectual
functioning is precluded; or
q Based on a valid verbal, performance, or full-scale IQ test, the person has an IQ of
59 or less; or
q Based on a valid verbal, performance, or full-scale IQ test, the person has an IQ
of 60 to 70 AND either (a) is unable to perform routine repetitive tasks; or (b) has
another mental capacity impairment that imposes additional and significant limitation
of mobility or gait.
q Other Organic Mental Capacity Impairment – The person experiences mental
incapacity due to an organic cause(s) that imposes significant limitations of
ambulation or gait.
Diagnosis:
I estimate that the duration of the applicant’s disability(ies) will be:
q Permanent (more than 12 months)
q Temporary (more than 3 but fewer than 12 months)
Physician’s/Certifier’s Signature: Date:
6
SECTION 5
(continued)
7
AUTHORIZATION TO DISCLOSE MY HEALTH INFORMATION
1. I hereby authorize: physician/certifier name:
Affiliation:
Address:
Tel. No.
to disclose the information as specified in paragraph 2 to: MTA Reduced-Fare Program, 130
Livingston Street, Brooklyn, NY 11201-9625.
2. (a) You are authorized to complete the "physician/certifier certification" section of my MTA Reduced-Fare
Program application and send it to the MTA; and, if contacted by MTA, you are authorized to discuss
with a representative of the MTA Reduced-Fare Program the information you have provided in the
"physician/certifier certification."
(b) This authorization is effective until the date of the termination of my receipt of MTA Reduced-Fare benefits.
(c) I am requesting that you disclose this health information for the purpose of enabling the MTA to
determine my eligibility for reduced-fare transportation benefits.
3. (a) I understand that my authorization is voluntary and that I may revoke it at any time by notifying you
in writing. I understand that if I do so, it is effective only to prevent any additional disclosure after the
date I give you my notice. It does not apply to disclosures that you made while my authorization was
in effect.
(b) I understand that once my health information is disclosed as authorized by me in this form, it may no
longer be subject to privacy protections if the authorized recipient is not obligated under law to protect
the privacy of my health information.
(c) I understand that you may not condition my treatment, payment, enrollment or eligibility for benefits
from you on my granting an authorization for disclosure/release of my health information.
Signature of Individual (applicant for the MTA Reduced Fare Program) Date:
Print the name and address of the individual (applicant for reduced fare) whose health information is to be
disclosed:
Name:
Address:
Tel. No.:
If this form has been signed by a personal representative, he/she must complete and sign the following:
I am the personal representative of the individual requesting disclosure of health information whose name
and address appear above. This individual has authorized me to complete this form on his/her behalf.
My relationship to the individual is as follows (e.g., parent, guardian, attorney, friend, etc.):
Signature of Personal Representative: Date:
Print Name of Personal Representative: Tel. No.
Address:
HIPAA-Compliant
8
Valid Use: RFM can be used to pay fares on all MTA New York
City Transit subways, NYC Transit local buses, express buses
only during non rush hours, MTA Staten Island Railway, Nassau
Inter-County Express Bus (NICE), MTA Bus, Roosevelt Island
Tram, Westchester Bee-Line local buses and express Bee-Line
BxM4C buses only during non rush hours.
The RFM is valid identification for eligibility in the reduced-
fare programs of the MTA Long Island Rail Road and MTA
Metro-North Railroad, anytime except weekday rush hours to
New York City terminals. To receive the reduced fare, show
the RFM to train personnel or station agents when
purchasing your ticket.
Expiration Dates: Reduced-Fare MetroCards expire on the
date printed on the back of the card. As long as you actively
use your card, NYC Transit automatically sends you a new
RFM before the expiration date.
The full value on an expired RFM may be transferred to a new
RFM at a subway station booth. Any remaining value that is
not transferred to a new RFM within two years after the
expiration date on the original RFM will be surrendered by,
and unavailable to, the card holder.
Trouble Using RFMs: An RFM that does not work or is
damaged should be returned to MetroCard Customer
Claims. Ask a station booth agent or bus operator for a
prepaid envelope in which to return your card to us. In the
envelope you’ll find a form to fill out so you can describe your
RFM problem.
If you prefer, you may bring your damaged RFM to the
MetroCard Customer Service Center at 3 Stone Street in
downtown Manhattan, 9 AM to 5 PM, Monday to Friday.
If you cannot get a prepaid mailer, send the damaged card to
our mailing address at:
MetroCard Customer Claims
130 Livingston Street
Brooklyn, New York 11201-9625
Be sure to include your name, address and phone number,
your damaged RFM, an explanation of the problem and the
address to which the new RFM should be sent.
The holder assumes the risk of loss until the card is received
by either MetroCard Customer Claims or the MetroCard
Service Center.
Change of Address: Notices and replacement cards will be
sent to you at the address you provide. You must inform us
promptly, in writing, of any change of address.
Lost or Stolen RFMs: Immediately report a lost or stolen
RFM by calling the MetroCard Customer Service Center,
718-330-1234, 6 AM to 10 PM or via our MetroCard eFIX
system at www.mta.info. Any value or unlimited rides on your
card will be transferred to your replacement RFM after the
old RFM has been frozen and any balances verified.
Restrictions: An RFM may be used only by the person to
whom it has been validly issued. Use of the RFM by any other
person may result in forfeiture of the card and its remaining
balances, plus civil and/or criminal penalties.
You must present your Reduced-Fare MetroCard to a police
officer or transit personnel upon request.
There are no refunds of money remaining on RFMs. Money
remaining on an expired card may only be transferred to a
new card within two years of the expiration date. Money from
a full-fare MetroCard cannot be transferred to a temporary or
permanent RFM. No redemptions or exchanges will be given
for an RFM that has been altered or tampered with, or whose
value cannot be verified.
The City of New York, the State of New York, the County of
Westchester and the Metropolitan Transportation Authority and
its subsidiaries and affiliates, including New York City Transit,
are not liable for any special or consequential damages
associated with or resulting from the failure, malfunction, or
disabling of the RFM or the MetroCard system.
The MTA Reduced-Fare MetroCard and its use are subject
to all tariff provisions, rules and regulations of the New
York City Transit Authority and its affiliates, and
Westchester County Bee-Line System.
For more information, call 718-330-1234 6 AM to 10 PM. If you are deaf or hard of hearing, use the free 711 relay
or your preferred relay service provider to contact us. Have the card at hand so you can read the serial number
and expiration date to the customer service agent who assists you.
MTA Reduced-Fare MetroCard
Conditions of Use and Other Important Information
for a Metropolitan Transportation Authority Reduced-Fare MetroCard (RFM)
issued to people 65 years of age and older and people with disabilities.
This program is managed by MTA New York City Transit.
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People with Disabilities (Metropolitan Transportation Authority)

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Completed 28 December 2022

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