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The Metrolift Application form is a crucial document designed to assess eligibility for METROLift services, a transportation option for individuals with disabilities who cannot use standard bus services. It requires detailed information about the applicant's mobility, medical conditions, and ability to navigate public transportation. Completing this form accurately is essential for ensuring that individuals receive the appropriate support and services they need.

Outline

The METROLift Application form is an essential document for individuals seeking paratransit services due to disabilities that prevent them from using standard public transportation. This form, spanning multiple pages, requires detailed personal information, including the applicant's name, contact details, and social security number. It also gathers crucial insights into the applicant's disability, mobility aids, and ability to navigate public transport independently. Pages 1 through 4 focus on the applicant's functional capacity and medical impairment, while pages 5 and 6 must be completed by a qualified healthcare professional. Their certification is vital for determining eligibility. The form emphasizes the importance of accuracy, as the information provided directly influences the assessment process. Assistance from family members or caregivers is encouraged to ensure thorough completion. Should any questions arise during the application process, METROLift Customer Service is available for support. Completing this form is the first step toward accessing vital transportation services that enhance mobility and independence.

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?

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

City/Ciudad

State/Estado

Zip Code/Codigo Postal

If different from home address/Si diferente de domicilio

Applicant Signature (required)

Firma

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?			Yes		No
If “no,” please explain.

5.Can you find your way to a bus stop without getting lost? If "no," please explain.

Yes

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?	Yes	No
Can you ask the driver where the bus is going?	Yes	No
Can you give or write a note to the driver?	Yes	No
Can you understand the driver's answer?	Yes	No
If "no" to any questions, please explain.

METRO 0447-17-(06/22)

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

Yes

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?	Yes
If "yes," please explain

15.Can you wait independently alone at your residence and places to which you travel?

Yes No

If "no," please explain.

METRO 0447-17-(06/22)

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: ____________________

METRO 0447-17-(06/22)

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?	Yes	No
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?

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.

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)

(L)

Date of Testing:

11.

If cognitively impaired, what is the applicant’s cognitive age, and IQ level?

12.

Is the applicant a wheelchair user?

Yes

If yes, how often

13.

Does the applicant use other mobility aids?

Yes

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

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Fact Name	Description
Application Purpose	The METROLift application form is designed to assess an individual's eligibility for METROLift services, which provide transportation for those unable to use regular bus services due to disabilities.
Information Requirement	Applicants must provide detailed information about their disability, functional capacity, and any assistive devices used. This information is crucial for determining eligibility.
Medical Certification	Pages 5 and 6 of the application must be completed and certified by a physician or certified health professional who understands the applicant's medical condition.
Assistance Allowed	Applicants may receive help from friends, family members, or caregivers when completing the application to ensure accuracy and completeness.
Contact Information	Applicants are required to provide their contact information, including home and emergency phone numbers, to facilitate communication regarding their application status.
Signature Requirement	The applicant's signature is mandatory on the application to confirm that the information provided is true and accurate, as well as to authorize the release of medical information.
Compliance with ADA	The application process is governed by the Americans with Disabilities Act (ADA) of 1990, which mandates that public transportation services must accommodate individuals with disabilities.
Consequences of Misrepresentation	Providing false information or failing to comply with the application process can lead to denial or termination of METROLift services.

Completing the METROLift Application form is an important step in seeking transportation services. It is essential to provide accurate and thorough information to determine eligibility. The application consists of several sections that require personal details, mobility information, and medical certification. After filling out the form, it will be reviewed to assess your needs and situation.

Begin by entering your Client ID number, if applicable, and the date the application is being filled out.
Provide your name, including last name, first name, and middle initial.
Fill in the last four digits of your Social Security Number.
Enter your complete address, including apartment number, city, and zip code.
Indicate your date of birth.
List your home phone number and any additional phone numbers.
If you live in an apartment complex, provide the name and gate code if applicable.
Fill in your mailing address if it differs from your home address.
Sign and date the application, confirming the accuracy of the information provided.
Provide the name and relationship of your emergency contact, along with their phone number.
Describe your disabilities and any assistive devices you use for travel.
Identify the nearest street intersection to your home.
Answer whether you can travel to that intersection without assistance.
Indicate if you can find your way to a bus stop without getting lost.
Specify how long you can wait for a bus.
Answer questions regarding your ability to read bus destination signs and communicate with the driver.
Describe your experiences with METRO's local fixed-route bus service.
Provide details about your current travel methods and whether you require someone to accompany you.
Complete the Agreement and Authorization section, confirming the truthfulness of your information.
If someone else filled out the form for you, include their name, relationship, and signature.
Ensure that pages 5 and 6 are completed and certified by a physician or certified health professional.

What is the purpose of the METROLift application form?

The METROLift application form is designed to gather information about an individual's ability to use METRO bus services. It assesses eligibility for METROLift, a paratransit service for individuals with disabilities who are unable to use local bus transportation.
Who can assist in completing the application?

A friend, guardian, caregiver, agency service representative, or family member may help the applicant fill out pages 1 to 4 of the application. This support can ensure that all necessary information is provided accurately.
What information is required from the applicant?

Applicants must provide personal information such as their name, address, date of birth, and Social Security number (last four digits). They must also describe their disability, any assistive devices used, and their ability to navigate to a bus stop.
What role does a physician or certified health professional play in the application process?

Pages 5 and 6 of the application must be completed and certified by a physician or certified health professional. This professional should be familiar with the applicant's impairment or condition, as their input is essential for determining eligibility.
What happens if the information provided is incomplete or inaccurate?

If the application contains incomplete or unclear information, METROLift may need to contact the applicant or their healthcare provider for clarification. Providing false or misleading information can result in denial of services.
How can an applicant contact METROLift for assistance?

Applicants can reach out to METROLift Customer Service by calling 713-225-0119 for any questions or assistance needed while completing the application.
What should be included in the emergency contact section?

The applicant must provide the name of an emergency contact, their relationship to the applicant, and a phone number where they can be reached. This information is important for ensuring safety during transportation.
What are the consequences of not following METROLift guidelines?

Failure to follow METROLift guidelines, including not cooperating with staff or demonstrating disruptive behavior, may lead to suspension or termination of services. It is important for applicants to understand and adhere to the established rules.
What should an applicant do if their condition changes?

If an applicant's condition changes in a way that affects their mobility, they are required to inform METROLift promptly. This ensures that the service can continue to meet their needs appropriately.
What types of disabilities are considered for METROLift eligibility?

The application allows for various disabilities to be reported. These may include physical, cognitive, or sensory impairments that prevent an individual from using the standard METRO bus service. Each case is evaluated based on the information provided.

Filling out the METROLift Application form can be straightforward, but many applicants make common mistakes that can lead to delays or issues with their eligibility. One frequent error is failing to answer all questions completely. The application requires detailed information about your disability and mobility capabilities. Incomplete responses can hinder the assessment process, as METROLift needs comprehensive data to determine eligibility.

Another mistake is not providing accurate contact information. Applicants sometimes enter incorrect phone numbers or addresses, which can complicate communication. If METROLift needs to reach you for clarification or updates, having the right information is crucial. Double-checking this section before submission can save time and prevent unnecessary back-and-forth.

Many individuals overlook the importance of the physician's certification on pages 5 and 6. This part must be completed by a healthcare professional familiar with the applicant's condition. Some applicants mistakenly think they can skip this step or use outdated information. Ensuring that a qualified professional fills out this section accurately is vital for the application to be processed.

Providing inconsistent information is another common issue. Applicants may describe their mobility challenges differently in various sections, leading to confusion. Consistency is key. If you state that you can walk a certain distance in one part of the form, but later indicate that you cannot walk at all, this discrepancy can raise red flags and delay approval.

Additionally, some applicants fail to explain their limitations thoroughly. When asked to describe why they cannot use the METRO bus service, vague answers can lead to misunderstandings. Providing specific details about your mobility challenges helps METROLift understand your situation better and assess your needs accurately.

Lastly, neglecting to sign and date the application is a critical oversight. Without your signature, the application is considered incomplete. Ensure that you review the entire form before submission, confirming that all required signatures are present. This final check can prevent unnecessary delays in processing your application.

The METROLift Application form is a crucial document for individuals seeking paratransit services in Houston. Along with this application, several other forms and documents may be required to ensure a comprehensive assessment of eligibility. Below is a list of these documents, each serving a unique purpose in the application process.

Proof of Residency: This document verifies the applicant's current address and may include utility bills, lease agreements, or government correspondence.
Medical Documentation: A letter or report from a healthcare provider detailing the applicant's medical condition and how it impacts their mobility. This supports the claims made in the application.
Emergency Contact Form: This form provides information about an emergency contact person, including their relationship to the applicant and how to reach them in case of an emergency.
Authorization for Release of Information: This form allows healthcare providers to share the applicant's medical information with METRO, ensuring that all necessary details are available for the eligibility determination.
Mobility Assessment Form: A specific evaluation conducted by a healthcare professional that assesses the applicant's ability to navigate public transportation independently.
Income Verification: Documentation such as pay stubs or tax returns that may be required to assess eligibility based on financial need or to qualify for reduced fare programs.
Identification Documents: A copy of a government-issued ID, such as a driver's license or state ID, to confirm the identity of the applicant.
Transportation History Form: This form collects information about how the applicant currently travels, including any previous use of public transportation services.
Personal Statement: A written statement by the applicant describing their mobility challenges and any additional context that may assist in the evaluation process.

Collectively, these documents provide a comprehensive view of the applicant's needs and circumstances. Ensuring that all required forms are completed and submitted can significantly enhance the chances of a successful application for METROLift services.

Social Security Disability Application: Similar to the Metrolift Application, this document requires personal information, medical history, and an evaluation of the applicant's ability to work due to a disability.
Medicaid Application: Like the Metrolift form, this application asks for detailed personal and financial information to determine eligibility for healthcare services for individuals with disabilities.
Supplemental Nutrition Assistance Program (SNAP) Application: This document also gathers personal information and details about an applicant's financial situation to assess eligibility for food assistance.
Americans with Disabilities Act (ADA) Accommodation Request: This request form requires information about the applicant's disability and the accommodations needed, paralleling the need for detailed information in the Metrolift Application.
Housing Assistance Application: Similar to the Metrolift form, this application collects personal data and information about the applicant's living situation to determine eligibility for housing support.
Veterans Affairs Disability Benefits Application: This document requires personal and medical information to evaluate eligibility for benefits, akin to the requirements in the Metrolift Application.
Long-term Care Insurance Application: Like the Metrolift Application, this document seeks detailed health information to assess the applicant's need for long-term care services.
Public Transportation Paratransit Application: This application, similar to the Metrolift form, requests information about the applicant’s mobility challenges and transportation needs to determine eligibility for paratransit services.
Disability Parking Permit Application: This document requires personal and medical information to evaluate the need for accessible parking, reflecting the information-gathering aspect of the Metrolift Application.
Employment Accommodations Request: Similar to the Metrolift Application, this request form collects information about the applicant's disability and the specific accommodations needed to perform job duties.

If "no" or "sometimes," please explain.

If "no" or "sometimes," please explain.

4. Can the applicant walk up and down two steps?

When filling out the METROLift Application form, it is important to approach the task with care. Here are some key things to do and avoid:

Do Answer all questions completely. This ensures that METROLift can assess your eligibility accurately.

Do: Seek help from a friend or family member if needed. They can assist you in providing the necessary information.

Do: Provide accurate details about your medical condition and functional capacity. This information is crucial for your application.

Do: Ensure that pages 5 and 6 are completed by a qualified physician or health professional. Their certification is required.

Don't: Leave any questions blank. Incomplete applications may lead to delays or denial of service.

Don't: Provide false information. Misleading details can result in denial of METROLift services.

Misconceptions

Misconception 1: The METROLift application is only for those who are completely unable to use public transportation.

This is not true. The application is designed for individuals with varying degrees of mobility impairments. Even if someone can use public transportation occasionally, they may still qualify for METROLift services.

Misconception 2: You must fill out the entire application by yourself.

In fact, a friend, family member, or caregiver can assist you in completing the application. Their help can ensure that all necessary information is accurately provided.

Misconception 3: The application process is quick and does not require detailed information.

The application requires comprehensive information about your medical condition and functional abilities. Providing complete and accurate details is essential for determining eligibility.

Misconception 4: A doctor’s signature is not necessary for the application.

Pages 5 and 6 of the application must be completed and certified by a physician or certified health professional. This step is crucial for verifying your condition.

Misconception 5: METROLift services are available to anyone who applies.

Approval is based on eligibility criteria. Not everyone who applies will be granted access to METROLift services.

Misconception 6: You cannot receive assistance while using METROLift.

Individuals who qualify for METROLift can travel with a companion or caregiver. This support can help make the journey easier.

Misconception 7: The application does not require personal information.

Personal details, including your address and social security number, are necessary for processing your application and ensuring accurate service delivery.

Misconception 8: If you are denied, you cannot reapply.

You can reapply for METROLift services if your circumstances change or if you can provide additional information that may support your eligibility.

Misconception 9: The METROLift application is only for individuals with physical disabilities.

The application is also for individuals with cognitive or sensory impairments. All types of disabilities that affect mobility are considered.

Key takeaways

Here are some key takeaways about filling out and using the METROLift Application form:

Complete All Sections: Make sure to fill out every part of the application, especially pages 1 to 4. Incomplete applications may delay the eligibility process.

Get Help if Needed: If you find it difficult to complete the application, ask a friend, family member, or caregiver for assistance.

Provide Accurate Information: It's essential to give truthful details about your medical condition and mobility. This information is crucial for determining your eligibility.

Physician Certification Required: Pages 5 and 6 must be filled out and signed by a physician or certified health professional familiar with your condition.

Emergency Contact: Include the name and phone number of someone who can be contacted in case of emergencies.

Understand the Agreement: Read the agreement and authorization section carefully. You must understand the implications of providing false information.

Submit the Application: Once completed, send the application to the address provided: 1900 Main P.O. Box 61429, Houston, TX 77208-1429.

Contact Customer Service for Questions: If you have any questions while filling out the form, call METROLift Customer Service at 713-225-0119 for assistance.