7.20.22 OUTBoard Agenda Packet - Laserfiche WebLink

Browse Search

Orange Public Transportation Health Care Professional ADA Paratransit Verification of Eligibility As a requirement of the Americans with Disabilities Act of 1990 (ADA), Orange Public Transportation is a federally subsidized public transportation service set aside for passengers who are prevented from using fixed-route service due to a mobility limitation. ADA paratransit service is not intended to include persons who find it inconvenient or even difficult to get to or from fixed-route bus stops. Disability alone is not an automatic qualifying determinant for ADA paratransit bus service. As a medical provider, you are uniquely familiar with the general health and abilities of your patient. As such, please provide answers to the following questions as they relate to mobility limitations resulting from a functional or cognitive disability. ALL INFORMATION FOR VERIFICATION OF ELIGIBILITY MUST BE FILLED IN BY A QUALIFIED HEALTH CARE PROFESSIONAL. PERSON COMPLETING VERIFICATON: _________________________________________________________________________ PROFESSIONAL TITLE: _________________________________________________________________________ AGENCY AFFILIATION: _________________________________________________________________________ STATE OF NORTH CAROLINA CERTIFICATION ID#______________________________ BUSINESS ADDRESS: _____________________________________________________ Street Ste. # _________________________________________________________________________ City State Zip BUSINESS PHONE NUMBER ________________________________________________ If you mark NO or SOMETIMES on any of the following items, please explain. 1)What is the medical diagnosis that causes the disability? (e.g. epilepsy, intellectual & development disability) ___________________________________________________________________ Is this condition: Temporary _____ Permanent _____ If temporary, what is the expected duration? ________________________________ Dates of Duration 30