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Orange County Transportation Services ADA Paratransit Plan 39 <br /> Authorization for Release of Information <br /> I authorize the professional who has completed Part B of this application to release to Orange County Public <br /> Transit information about my disability or health condition and its effect on my ability to travel on the <br /> Orange County Public Transit (OCTS) bus service. I understand that I may revoke this authorization at any <br /> time. <br /> 1, the applicant, understand that the purpose of this application is to determine my eligibility to use the <br /> ADA complementary paratransit services. I agree to release the information requested Orange County <br /> Public Transit, and any eligibility review panel, and understand that the information contained herein are <br /> treated confidentially, unless otherwise required by law. I understand further that Orange County Public <br /> Transit reserves the right to request additional information at its discretion. I agree to notify Orange County <br /> Public Transit of any changes in the status of my disability that affects my ability to use the ADA <br /> complementary paratransit service. I also understand that this may affect my eligibility as a rider. <br /> Applicant's Name <br /> Date of Birth <br /> Applicant's Address <br /> City State Zip <br /> Applicant's Telephone Number <br /> Date <br /> (Signature of Applicant or Responsible Party) <br /> Orange County Planning Department Page 33 <br />