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MEDICAL PROVIDER VEHICLE APPLICATION PROCEDURES

FOR YOUR CONVENIENCE YOU MAY RENEW BY MAIL

ALL FEES MUST BE IN THE FORM OF A MONEY ORDER, BUSINESS CHECK, or CREDIT CARD…NO CASH ACCEPTED

Applications will not be processed without ALL of the following. Failure to comply with any of the following

items will result in DENIAL of your application.

ALL APPLICATION FEES & MATERIALS ARE NON-REFUNDABLE, NON-RETURNABLE.

Supplying false information on this document may result in criminal charges being filed,

additional fees, fines, and/or denial of your application.

ITEM

INSTRUCTIONS / DOCUMENTS REQUIRED

Medical Provider Van/Vehicle : A medical provider van is a vehicle that is not wheelchair accessible and

is capable of carrying 8-14 passengers for the sole purposes of transporting passengers to and from

A medical provider vehicle is an automobile carrying 7 or fewer

medical appointments.

Eligibility

passengers for the sole purpose of transporting passengers to and from medical appointments

within Westchester County.

Payment for such transportation is made solely through contracts with

various health or social service organizations. These organizations include, but are not limited to,

Medicaid, NYS Department of Social Services, or schools/programs for the disabled.

Applications will not be accepted if they are not completely filled out and

Complete

Application

Notarized.

/ Affidavit(s)

Must supply original letter of authorization from the DOH.

Vehicle

Registration

Supply your New York State Department of Motor Vehicles Vehicle Registration, or “proof of ownership”

Proof of

(e.g. Title, Bill of Sale,” etc.) for vehicles not previously registered with the State DMV.

Ownership

Driver license

Supply a photocopy of your driver’s license.

Supply a photocopy of your FH-1

and

“Acord” Certificate of Liability Insurance.

Proof of

WCTL MUST BE NAMED AS “CERTIFICATE HOLDER” along with correct WCTLC address.

Insurance

Application

Fee:

Supply a money order or business check payable to “WCTLC." For a small service fee, payment by credit

card is also accepted at the service window.

$100.00

Late Fee:

Late renewal applications are required to pay a late fee.

$75.00

Replacement

When replacement of vehicle permit is necessary due to loss or destruction a vehicle application must

Fee

be filed and a replacement fee paid.

$75.00

Fingerprinting

Fee:

First-Time applicants only. The CRIMINAL BACKGROUND FORM must also be completed.

$90.00

Outstanding

fees

All outstanding fees and/or fines must be paid before submitting your application.

and/or fines

WCPD322 (Rev 09/2016)

Page 4 of 4

Form Wcpd322 - Medical Provider Waiver Application - Westchester County Taxi & Limousine Commission Page 4

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