Americans With Disabilities (Ada) Act Verification And Eligibility Form printable pdf download

Americans With Disabilities (Ada) Act Verification And Eligibility Form

Americans With Disabilities (ADA) Act

Verification and Eligibility Form

___________________ has submitted an application for eligibility for the IVT ACESSS Transit bus

service for persons with disabilities. This application includes a release to be used for the

verification of this condition on Page 4.

This form is for verification of___________________ regarding his/her disability and its impact

upon his/her ability to utilize our public bus service, IVT ACCESS.

Please fill out the following form and return it to our office at your earliest convenience

Patient's Name:

What is the diagnosis of the disability that qualifies for our ADA paratransit service?

Please be specific and list any relevant medical history

Is this disability Permanent or Temporary?

Permanent

Temporary

Medical Care Provider/Physician Information

Name

Telephone/Fax Number

Office Address (street, city, and zip code)

License Number or Professional Designation

Recommendation

(Please check one)

My Patient is eligible for this service on a permanent basis

My Patient is eligible for this service on a temporary basis

My Patient is not eligible for this service at this time

Medical Care Provider's Signature

Date

Phone: (760) 592-4494

ADA Certification Coordinator

1405 N. Imperial Ave., Suite 1

Fax:

(760) 592-4497

Imperial County Transportation Commission

El Centro, CA 92243

Americans With Disabilities (Ada) Act Verification And Eligibility Form