Fillable Reduced Fare Program for People with Disabilities (Washington Metropolitan Area Transport Authority)

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Reduced Fare Program for People with Disabilities (Washington Metropolitan Area Transport Authority)

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Reduced Fare Program for People with Disabilities
Under this program, people with disabilities may travel on
Metrobus and Metrorail for half the regular (rush hour) fare at all times.
Who should apply
People with disabilities who can use the accessible
bus and rail public transportation. See page four for
guidance on submitting the completed application.
The minimum age to apply for this program is 5
years old.
Who is not eligible
People whose sole incapacity is pregnancy,
obesity, acute or chronic alcoholism or drug
addiction or have a contagious disease. Financial
need is NOT a consideration.
Senior Citizens
People 65 years or older automatically qualify for
reduced fares through the Senior SmarTrip
®
. Senior
citizens can purchase a Senior SmarTrip
®
card by
showing a valid photo ID with proof of age at any
Metro Sales office, commuter store or other select
retail outlet. People 65 years or older cannot be
issued a Reduced Fare/SmarTrip
®
card.
Medicare Recipients
Under 65 Years of Age
Medicare recipients under the age of 65
automatically qualify for reduced fares and do not
need to complete an application. To receive the
Reduced Fare/SmarTrip
®
card, Medicare recipients
under 65 years of age must bring a valid photo
ID and their original valid Medicare ID card to the
Transit Accessibility Center at the address below.
Disabled Veterans
Disabled Veterans who have been granted a 60%
or greater disability rating by the Department of
Veterans Affairs do not need to complete Part
B or C of the application. The applicant must
appear in person at the Metro Transit Accessibility
Center, 600 5th Street, NW, Washington, DC with
a valid photo ID and an original or recently
downloaded letter of disability notification issued by
the Department of Veterans Affairs. Disabled
Veterans rated at 100% can show their valid DD
Form 2765 Department of Defense Uniformed
Services ID card in lieu of an award letter.
Completing the Application
1.
Read the entire application and complete Part
A on page two.
2.
Take the application to your healthcare
professional for certification of Part B & Part C
on page three. One of the following health care
professionals must certify you to qualify for a
Metro Disability ID Card: Physician, Physician’s
Assistant, Nurse Practitioner, Audiologist
(hearing disabilities only), Optometrist (visual
disabilities only), Podiatrist (foot and ankle
disabilities only), Licensed Clinical Psychologist
(psychiatric disabilities only) or Certified School
Psychologist.
3.
Healthcare professionals must review Part
C
Guidelines for Health Care
Professionals on page 3.
Washington Metropolitan Area Transit Authority | Transit Accessibility Center
600 5th Street NW | Washington DC 20001 | 202-962-2700
Between Judiciary Sq and Gallery Place Metrorail stations
50.706 Rev 07/16
Part A: Applicant Information and Release
Please provide all information in print or type.
Name (Last, First, MI): Date of Birth:
Street Address: Apartment:
City, State, Zip:
Phone / TTY/ Relay:
E-mail: Gender (circle): M F
Previous ID Cardholder (Circle) Yes
No
60+% Disabled Veteran (Circle)
Yes
No
Local Emergency Contact Relationship:
Address: Phone:
I authorize the health care professional completing this application to release to the Washington Metropolitan
Area Transit Authority (Metro) information about my disability.
Original Signature of Applicant (under 18, signature of parent or guardian) Date
Part B: Health Care Professional Certification
Please provide all information in print or type.
Part B must be completed by a licensed or certified health care professional (see page one) and must be received by Metro within 60 days
of the health care professional’s signature. Information on this application will remain on file with Metro and is not subject to public review.
Name of Health Care Professional:
License Number/State Issued: Phone:
Address: City, State, Zip:
Check one: Physician: (Specialty)
Physician’s Assistant
Nurse Practitioner
Audiologist Podiatrist
Optometrist
Licensed Clinical Psychologist
Certified School Psychologist
Review Part C: Guidelines for Health Care Professionals on page two and provide all appropriate guideline number(s) and
detailed information below regarding the applicant’s disability. Specific DSM or ICD code(s) and a specific diagnosis are required.
(MUST BE COMPLETED TODETERMINEELIGIBILITY)
Guideline Number(s) DSM Code(s) or ICD Code(s) Specific Diagnosis
Does the applicant require a personal care attendant to use public transportation all or sometimes?
______ Yes
_____ No
(Healthcare Provider Initial)
Original Signature of Health Care Professional Date
False certification may be reported to the licensing agency under District of Columbia Code Annotated, Section 2-3305.15, Code of Virginia 54.1-2915, or Maryland Health Occupations Code
Annota
ted14-404 or appropriate code for state of license or certification. Metro reserves the right to: (1)verify the validity of the license of the health care professional providing the certification, (2)
make the final determination on an applicant’s eligibility for the Metro Reduced Fare Program, and (3) retain a copy of this application.
WMATA USE ONLY
ID Card No. Issued by Expiration date
SmarTrip
®
card # Issued date
click to sign
signature
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Part C Guidelines for Health Care Professionals
The following guidelines are to be used to
determine eligibility for the Metro Reduced Fare
Program for People with Disabilities.
Health care professionals with questions, please
call 202-962-2700.
1.
NON-AMBULATORY: An individual is unable
to walk and requires the use of a wheelchair
or other mobility device.
2.
SEMI-AMBULATORY: An individual has a
chronic condition which
substantially limits
the ability to walk, or is unable to walk
without the use of a caliper leg brace, walker
or crutches.
3.
AMPUTATION: An individual has an
amputation of one or both hands, arms, feet
or legs.
4.
STROKE: An individual has substantial
functional motor deficits in any of two
extremities, loss of balance and/or cognitive
impairments three months post stroke.
5.
NEUROLOGICAL CONDITIONS OTHER
THAN STROKE: An individual has difficulty
with coordination, communication, social
interaction and/or perception from a brain,
spinal or peripheral nerve injury or illness,
has functional motor deficits, or suffers
manifestations that significantly reduce
mobility. A specific diagnosis is required.
6.
PULMONARY OR CARDIAC CONDITIONS:
An individual has a pulmonary or cardiac
condition resulting in marked limitation of
physical functioning and dyspnea during
activities such as climbing steps and/or
walking a short distance. If diagnosis is
asthma, please state whether: a)
individual has been on systemic medication
for the immediate past six months, OR b)
individual has been required to use fast
acting inhaler for three or more episodes
per week for the immediate past six
months. A specific diagnosis is required.
7.
BLIND OR LOW VISION: An individual is
legally blind, whose visual acuity in the better
eye, with correction, is 20/200 or less, or
who has tunnel vision to 10 degrees or less
from a point of fixation or so the widest
diameter subtends an angle no greater than
20 degrees. An individual has low vision, and
whose visual acuity is in the range of 20/70 to
20/200 with best correction.
8.
DEAF OR HARD OF HEARING: An individual
with a pure tone average greater than
70 dB in both ears, regardless of use of
hearing aids.
9.
EPILEPSY: An individual has had at least
one tonic-clonic seizure within the past
four months.
10.
DEVELOPMENTAL OR LEARNING
DISABILITIES: An individual has a significant
learning, perceptual and/or cognitive
disability. Some conditions are excluded
from eligibility such as attention deficit
disorder (ADD) and ADHD. A specific
diagnosis is required.
11.
MENTAL ILLNESS: An individual whose
mental illness includes
a substantial
disorder of thought, perception, orientation,
or memory that impairs judgment and
behavior. A specific diagnosis is required.
12.
CHRONIC PROGRESSIVE DEBILITATING
CONDITIONS: An individual who experiences
debilitating diseases, autoimmune
deficiencies or progressive and uncontrollable
malignancies, any of which are characterized
by fatigue, weakness, pain and/or changes
in mental status that impair mobility. A
specific diagnosis is required.
13.
Financial need is NOT a consideration.
Submitting your application
Bring the original, completed application to
the Transit Accessibility Center located on the
lobby level of Metro Headquarters, 600 5th
Street,
NW. Applications are processed on
Mondays, Wednesdays ,Thursdays and Fridays
from 8:15 a.m. to 3:50 p.m., Tuesdays from 8:15
a.m. to 2:20 p.m. The office is closed on
weekends and federal holidays. The application
must be received by Metro within 60
days of
the healthcare professional’s signature.
Applications will not be accepted by mail or fax.
Eligible applicants must bring
The original, completed application, a valid photo
ID (One of the following: Drivers’ license, non-
drivers ID, passport, government or school-issued
ID card). Disabled Veterans must bring their
original or downloaded letter of disability notification
issued by the Department of Veterans Affairs or
DD Form 2765
if rated at 100% and the original,
completed part A of the application. Medicare
recipients under the age of 65 must bring a valid
photo ID and a current Medicare card.
Groups
For large groups of ten or more, contact the
Transit Accessibility Center at 202-962-2703 or
traveltraining@wmata.com for information about
arranging an on-site photo ID session.
Ownership of a
Metro Disability ID card
The valid Metro Disability ID Card must be in the
possession of the cardholder at all times while
riding Metrobus and Metrorail. The Reduced Fare
SmarTrip
®
ID card must be presented when paying
by cash on Metrobus, or on demand to Metro
Transit Police Officers, Metrobus operators, and
Metrorail station managers. Metro Reduced Fare/
SmarTrip
®
ID cards used in any unlawful manner will
be confiscated.
Replacing a lost card
ALL REDUCED FARE CUSTOMERS MUST
PERIODICALLY RENEW THEIR ELIGIBILITY
FOR THE PROGRAM WITHIN 60 DAYS OF THE
EXPIRATION DATE FOUND ON THE FRONT OF
THE REDUCED FARE ID CARD.
If you lose your valid Metro Reduced Fare/
SmarTrip
®
ID card, you may obtain a replacement.
A fee of $10 is charged for the first replacement
and $25 for each subsequent replacement. The
fee may be waived upon receipt of a police report
documenting theft of your Metro Reduced Fare/
SmarTrip
®
ID, or if the card is tattered or damaged.
Renewing yourcard
You must complete a new application to renew
your Metro Reduced Fare/SmarTrip
®
ID Card.
You can’t reapply more than 30 days prior to the
current expiration date on your Reduced Fare/
SmarTrip
®
ID.
Appeal process
If you are determined ineligible for the Reduced
Fare Program for People with Disabilities, you
may appeal the decision. To obtain a copy of the
Reduced Fare Program Appeal Process, contact
the Metro Office of ADA Programs at 202-962
-
1100
or adap@wmata.com.
Learn how to use Metro
Metro can help customers with disabilities learn
how to use the Metro system for travel around the
region. For more information, or to schedule a free
travel training session, please contact 202-962
-
2703 or traveltr
aining@wmata.com.
Eligibility determinations are governed by the
Metro Reduced Fare Program policies in effect
on the date the application is received by the
Transit Accessibility Center.
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Completed 27 June 2021

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