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42 <br /> ORANGE COUNTY <br /> NORTH TH AR01.f1 A <br /> Orange Public Transportation <br /> Health Care Professional <br /> ADA Paratransit Verification of Eligibility <br /> As a requirement of the Americans with Disabilities Act of 1990 (ADA), Orange Public <br /> Transportation is a federally subsidized public transportation service set aside for <br /> passengers who are prevented from using fixed-route service due to a mobility limitation. <br /> ADA paratransit service is not intended to include persons who find it inconvenient or even <br /> difficult to get to or from fixed-route bus stops. Disability alone is not an automatic qualifying <br /> determinant for ADA paratransit bus service. As a medical provider, you are uniquely <br /> familiar with the general health and abilities of your patient. As such, please provide <br /> answers to the following questions as they relate to mobility limitations resulting from a <br /> functional or cognitive disability. <br /> ALL INFORMATION FOR VERIFICATION OF ELIGIBILITY MUST BE FILLED IN BY A <br /> QUALIFIED HEALTH CARE PROFESSIONAL. <br /> PERSON COMPLETING VERIFICATON: <br /> PROFESSIONAL TITLE: <br /> AGENCY AFFILIATION: <br /> STATE OF NORTH CAROLINA CERTIFICATION ID# <br /> BUSINESS ADDRESS: <br /> Street Ste. # <br /> City State Zip <br /> BUSINESS PHONE NUMBER <br /> If you mark NO or SOMETIMES on any of the following items, please explain. <br /> 1) What is the medical diagnosis that causes the disability? (e.g. epilepsy, intellectual <br /> & development disability) <br /> Is this condition: Temporary Permanent <br /> If temporary, what is the expected duration? <br /> Dates of Duration <br />