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The METROLift Application form is an essential document for those seeking access to specialized transportation services in the Houston area. It is designed to gather important information regarding an applicant's ability to utilize standard METRO bus services. This multi-page form not only requires personal details, such as name, address, and contact information, but also delves into individual mobility needs and functional capabilities. It invites applicants to provide insights about their disabilities and the assistive devices they use, outlining specific questions that help assess their eligibility for METROLift's services. Furthermore, pages 5 and 6 demand certification from a physician or health professional, ensuring that the assessment of mobility challenges is thorough and accurate. It is crucial for applicants to complete all sections, as incomplete responses may hinder the determination process. This comprehensive application aims to understand each individual’s unique situation better while ensuring that METROLift effectively serves those who genuinely require more tailored transportation solutions.

Metrolift Application Example

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?

No

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

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

No

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

No

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:

No

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

 

No

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?

Yes

No

Sometimes

 

 

 

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

 

 

 

 

 

 

 

 

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

Yes

No

Sometimes

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.

9.

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

 

No

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

Get Metrolift Application PDF Form

Form Characteristics

Fact Name Fact Description
Eligibility Assessment The METROLift application is designed to assess an applicant's ability to use public transit services. It requires detailed information regarding the applicant's medical impairments and functional abilities to make an accurate eligibility determination.
Assistance from Others Applicants may receive help from family members, friends, or caregivers to fill out their application. It is essential to provide thorough and truthful information, as incomplete submissions may hinder the eligibility process.
Medical Certification Requirement Pages 5 and 6 of the application must be completed and certified by a qualified physician or health professional familiar with the applicant’s condition. This requirement ensures that the information reflects the individual’s true health status.
Legal Framework The METROLift service operates under the Americans with Disabilities Act of 1990, which mandates that public transit systems provide complementary paratransit services to individuals with disabilities, ensuring their access to public transportation.

Guidelines on Utilizing Metrolift Application

Filling out the METROLift Application form requires attention to detail. Taking the time to provide accurate information can make a big difference. You will need some personal information, as well as details regarding your ability to use the METRO bus service. Below are the steps to follow when completing the form.

  1. Obtain the Form: Get the METROLift Application form from the appropriate source.
  2. Personal Information: Fill in your full name including last, first, and middle initial.
  3. Social Security Number: Enter the last four digits of your Social Security Number.
  4. Address: Provide your home address, including apartment number, city, and zip code.
  5. Date of Birth: Input your date of birth.
  6. Phone Numbers: List your home phone number and any other relevant phone number.
  7. Mailing Address: If your mailing address is different from your home address, include that information.
  8. Signature: Sign and date the application.
  9. Emergency Contact: Provide the name, relationship, and phone number of an emergency contact.
  10. Mobility Information: Answer questions regarding your disabilities, assistive devices, and mobility abilities.
  11. Travel History: Describe how you currently travel, including any support you may need.
  12. Certification by a Physician: Make sure to have pages 5-6 completed and certified by a physician or certified health professional.
  13. Preparer Information: If someone else is helping you fill out the form, provide their name, phone number, relationship, and signature.

What You Should Know About This Form

What is the purpose of the METROLift application form?

The METROLift application form is designed to gather essential information about individuals who may require paratransit services due to a disability. This information helps determine an applicant's eligibility for METROLift services, which offers transportation assistance for those unable to utilize the standard METRO bus services. Completing the application accurately is crucial to ensuring that appropriate services can be provided.

Who can assist in completing the application?

Individuals may seek help from various sources when filling out the application. A friend, family member, caregiver, or agency service representative can assist in providing accurate answers on pages 1–4 of the form. This collaborative approach can be vital, especially for applicants who might need support in articulating their needs or understanding the questions posed.

What information is required on the application?

The application requires personal information, including the applicant’s name, address, and date of birth. Additionally, it solicits details regarding the applicant's disability, use of assistive devices, and ability to navigate to a bus stop independently. Pages 5–6 must be completed by a certified healthcare professional, who will evaluate the applicant’s medical condition and functional capacity.

Why is certified healthcare professional information necessary?

Pages 5 and 6 must be completed and certified by a physician or a certified health professional to ensure that the assessment of the applicant's mobility limitations is accurate and credible. This certification plays a critical role in the eligibility determination process since it provides an objective evaluation of the applicant's condition and capabilities, which is necessary for providing appropriate transit services.

What happens if I provide false information on the application?

Providing false or misleading information on the METROLift application can have serious repercussions. It may result in denial of services or lead to suspension and/or termination of existing services. The integrity of the information provided is crucial, as it impacts the safety and effectiveness of the transportation services that METROLift offers.

How do I check the status of my METROLift application?

For inquiries about the status of an application, individuals should reach out directly to METROLift Customer Service at 713-225-0119. The customer service team can provide updates and assist with any additional questions or concerns regarding the application process.

Can I amend my application after submission?

Yes, applicants may need to update their application if they experience changes in their condition or contact information. It is essential to keep METROLift informed of any significant changes that may affect eligibility or service needs to ensure that the transportation services remain appropriate and effective.

What if I cannot use public transportation at all?

If an applicant is unable to use public transportation due to their disabilities, they should clearly state these limitations in their application. Describing specific barriers and challenges they face while using local fixed-route bus services will aid in properly assessing their eligibility for METROLift and ensuring they receive the support they require.

Common mistakes

Completing the METROLift application form can be a straightforward process, but applicants often make mistakes that can delay their eligibility determination. One common error is failing to answer all questions completely. The instructions clearly state that every question must be addressed. Omitting information can lead to confusion and an incomplete application, ultimately resulting in denial or delay.

Another frequent mistake involves providing inaccurate or incomplete information about one's disability or functional capacity. The form requires detailed descriptions of disabilities, yet some applicants may not take the time to offer sufficient explanation. This lack of thoroughness may prevent the reviewers from understanding the applicant’s needs, which is essential for assessing eligibility.

Also, not having a physician or certified health professional complete the required sections can be problematic for applicants. The form explicitly states that pages 5 and 6 must be filled out by someone familiar with the applicant's condition. If these pages are skipped or improperly filled, the overall application may be deemed invalid.

Many people overlook the importance of reviewing their application before submission. Small typographical errors, missing signatures, or incorrect contact information can cause significant delays. Ensuring accuracy and completeness during this review process can prevent unnecessary complications.

Some applicants may fail to provide a reliable emergency contact. The form asks for the name and phone number of an emergency contact, and a lack of this information may hinder communication in critical situations. Providing accurate contact details can streamline any necessary follow-up.

Another mistake involves misunderstanding the purpose of the application. While some view it as merely a requirement, understanding that this application establishes their eligibility for vital services is crucial. Providing thoughtful and precise answers can impact the support they receive from METROLift.

Additionally, questions related to the ability to navigate independently can be misinterpreted. Some applicants might not clearly understand what it means to find their way to a bus stop or identify a destination. Being specific in these responses helps clarify mobility capabilities.

Time management is also vital. Applicants should plan to complete the application without feeling rushed. Taking adequate time ensures that each question is answered thoroughly and thoughtfully. However, hurried submissions often lead to mistakes.

Furthermore, some applicants may not be aware that their medical condition might change over time. Including accurate information about their current state, rather than past health issues, is essential. Changes in health can influence eligibility and service needs.

In summary, by being mindful of these common errors, applicants can improve their chances of a smooth application process. Completing the METROLift application correctly is critical for securing necessary transportation services that enhance mobility and independence.

Documents used along the form

When applying for METROLift service, there are several documents that may be required in addition to the Metrolift Application form. Each of these documents plays a crucial role in determining eligibility and ensuring a smooth application process.

  • Medical Certification Form: This document is completed by a physician or certified health professional. It provides detailed information about the applicant's medical condition and ability to travel independently.
  • Proof of Residency: A document that verifies the applicant's current address. This could include a utility bill, lease agreement, or any official mail that clearly states the address.
  • Identity Verification: Commonly a copy of a government-issued ID, such as a driver's license or state ID. This confirms the applicant's identity and supports the application process.
  • Emergency Contact Form: This document provides essential contact information for a friend or family member who can be reached in case of an emergency. It is crucial for the safety of the applicant during transit.
  • Release of Information Authorization: A form that allows METRO to obtain relevant information from healthcare providers. This is important to confirm details about the applicant’s disability and mobility limitations.
  • Transportation History Form: This document collects information about the applicant's previous experiences with public transportation, including types of services used and any difficulties encountered. It helps assess individual needs better.

Gathering these documents alongside the Metrolift Application will contribute to a comprehensive review of your eligibility for METROLift services. Make sure to double-check that all required information is accurate and complete to facilitate the process.

Similar forms

  • Social Security Disability Insurance (SSDI) application: Similar to the Metrolift application, the SSDI application requires detailed personal information, including medical history and disability specifics, to assess eligibility for benefits.
  • Supplemental Nutrition Assistance Program (SNAP) application: Like the Metrolift application, this form gathers information regarding the applicant's financial status and family composition to determine eligibility for food assistance programs.
  • Medicaid application: This document demands comprehensive financial disclosure and medical information, paralleling the need for personally identifying information and physical condition details found in the Metrolift application.
  • Medicare application: It requires similar demographic data and information related to disability status, making it comparable in terms of thoroughness for eligibility assessment.
  • Unemployment benefits application: Individuals applying for unemployment benefits must provide personal and employment history information, akin to the Metrolift’s requirement for context surrounding mobility limitations.
  • Housing assistance application: This application also demands income verification and details about residency, paralleling the Metrolift process where residency information is critical.
  • Educational disability support application: Much like Metrolift, this document collects medical documentation and descriptions of limitations to determine eligibility for accommodations in educational settings.
  • Veteran's benefits application: Applicants must provide personal details, military history, and health conditions, similar to the information requested in the Metrolift form to support service eligibility.
  • Paratransit service application in other regions: These applications often follow a similar structure, collecting medical and personal information to assess the need for accessible transportation services just like Metrolift does.

Dos and Don'ts

Things to Do When Filling Out the METROLift Application Form:

  • Answer all questions carefully and completely.
  • Ensure accurate information is provided regarding your disability and functional capacity.
  • Have a qualified individual, such as a physician, complete the required sections on pages 5 and 6.
  • Sign and date the application form where indicated.

Things NOT to Do When Filling Out the METROLift Application Form:

  • Do not skip questions, even if they seem irrelevant.
  • Do not provide false or misleading information.
  • Do not forget to inform METROLift of any changes in your condition or contact information.
  • Do not attempt to complete the form without assistance if needed.

Misconceptions

Despite the importance of the METROLift Application form for those needing paratransit services, several misconceptions can lead to confusion. Here are six common misunderstandings:

  • It’s only for people with severe disabilities. Many believe that METROLift is only for individuals with significant mobility challenges. In reality, it’s designed for anyone who requires assistance due to a physical or cognitive impairment, regardless of its severity.
  • Assistance with the application is not allowed. A common myth is that applicants must fill out the application on their own. In fact, friends, family members, or caregivers can assist in completing the form to ensure accurate information is provided.
  • A physician’s signature is optional. Some think that the physician’s certification at the end of the application is not crucial. However, this step is mandatory. The healthcare professional’s input is essential to verify the applicant's conditions.
  • The application is too complicated. Many feel the form is overly intricate. While there are multiple questions, the application is structured to gather vital information simply and efficiently. Taking it step-by-step can help.
  • Submitting the form guarantees approval. There's a belief that completing the application guarantees METROLift service approval. However, eligibility is based on the assessment of the provided information and confirmation from the healthcare provider.
  • Eligibility for METROLift is permanent. Some applicants assume once approved, they will always qualify for METROLift. In fact, eligibility may be reviewed periodically, especially if there are changes in condition or mobility.

Key takeaways

Key Takeaways for the METROLift Application Form:

  • Complete pages 1-4 honestly and thoroughly to assist in determining your eligibility.
  • You may have assistance from a friend or family member while filling out the application.
  • Pages 5-6 require certification by a physician or certified health professional familiar with your condition.
  • Indicate any disabilities and assistive devices used during travel on the application.
  • Clearly specify your ability to navigate to a bus stop and wait for a bus.
  • Submit the required Emergency Contact information in case of issues during travel.
  • Understand that all information provided is confidential and used solely for eligibility assessment.
  • Falsifying information could lead to denial of services or termination if already approved.

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