Honored Citizen Application Form (Page 2 of 2) in pdf

Health care provider certification section:

This form is used for Individuals with permanent or temporary disabilities.

This also includes individuals who may need an attendant to ride TriMet service.

Patient/applicant release:

I authorize: _________________________________________________ to verify my disability if requested to do so by TriMet.

(Name of certified and/or licensed health care provider*)

Patient/applicant signature: ___________________________________ Date: _____________________________________

To be completed by

licensed health care provider*

(see below)

TriMet issued Agency stamp

Applicant’s name: _________________________________________

Applicant’s date of birth: ____________________________________

Health care provider’s name: _________________________________

HERE

Title: ____________________________________________________

State certification or license #: _______________________________

Telephone number: ________________________________________

_____________________________________________

Agency representative’s signature

Email address: ____________________________________________

_____________________________________________

Address: _________________________________________________

Address

_____________________________________________

_________________________________________________

Date

I, _________________________________________________ hereby certify that I have examined the patient listed above and

(Name of certified and/or licensed health care provider*)

it is my opinion that he/she is disabled due to illness, congenital malfunction or other incapacity that substantially limits one or

more major life functions.

Disability is:



Permanent



Temporary (defined as impairment lasting not more than 12 months). Duration is _______ months.

SPECIFIC

LEGIBLY

description of disability (Please print

and provide sufficient detail) or attach description on official letterhead form:

_______________________________________________________________________________________________________



yes

no Does the described disability necessitate that the applicant have an attendant to ride TriMet service?

I certify that the above is correct and that I am legally certified and/or licensed in my state as a Healthcare Provider.

Signature _______________________________________________________ Date __________________________________

Customer Service staff may contact you for verification.

Completed application and health care provider certification may be mailed to the TriMet Ticket Office, 701 SW 6th Avenue, Portland, OR 97204

503-962-2455 • •

*Physician, Physician Assistant, Licensed Clinical Social Worker, CADC (Certified Alcohol and Drug Counselor) , QMHP, Registered Nurse Practitioner, or

Counselor certified by the Addiction Counselor Certification Board of Oregon (ACCBO) .

**For the purpose of simplifying administration of the Honored Citizen Program, social service agencies or other organizations that are interested

in processing TriMet Honored Citizen Card Applications for their clients may be selected, at TriMet's discretion, to operate as a "Designated

Administrative Agency."

Honored Citizen Application Form Page 2

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