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Point Plus Eligibility Application / Specialized Transportation Certification

  1. Point Plus Eligibility Application / Specialized Transportation Certification

    The information obtained in this certification will only be used for the provision of Central Transportation specialized transportation services.

  2. Gender

  3. 1. Are you on medical assistance?*

    Otherwise known as Medicaid, Title XIX or MA. Not to be confused with Medicare.

  4. 2. Are you a member of any of the following social service agencies?

    (Please check all that apply)

  5. 3. Please check which best describes your current living situation:*

  6. 5. Is this condition temporary? *

  7. 6. Which of the following mobility aids do you use?

    (Please check all that apply)

  8. If you use a wheelchair or scooter, please provide the following information about the device.

    (Please note, individuals using mobility devices that exceed 30” in width and/or 48” in length may not be able to be accommodated. Also in situations where the applicant and their mobility device have a combined weight of more than 800 lbs. when occupied, Central Transportation may not be able to accommodate the ride.)

  9. 7. How far can you travel with or without the use of a mobility aid?*

  10. 8. How do you currently travel?*

    (Please check all that apply)

  11. 9. Do you travel with a Personal Care Attendant?*

  12. 10. Can you wait outside at a bus stop for 10-15 minutes?*

  13. 11. If you use a mobility device (e.g. wheelchair) can you get on and off a wheelchair lift independently?

  14. 12. Is your ability to travel affected by physical or natural barriers (distance, weather, lack of curbs, etc.)?*

  15. 13. Mark the box if it describes you.

    (Please check all that apply)

  16. 14. Mark the box if it describes you.

    (Please check all that apply)

  17. 15. If personalized travel training were provided to teach you how to ride the City Bus, would you participate?*

  18. Professional Verification

    In order for your application to be evaluated, it may be necessary to contact a physician or other professional to confirm the information you have provided. Please complete the following information and authorization form.

  19. The following professional is most familiar with my health condition and is authorized to provide Central Transportation with the information required to complete this certification.

    Registered Nurse, Case Manager, Rehabilitation Professional, Physical Therapist, Occupational Therapist, Mental Health Professional.

  20. I hereby authorize the above professional to provide the required information to Central Transportation. Furthermore, I understand it may be necessary for me to participate in an in-person evaluation to determine my eligibility for specialized transportation services. I certify that the information may result in denial of service. *

  21. I hereby agree that the information given is correct.*

  22. To the best of my knowledge the above information is true and factual. I understand that falsification, distortion, or misrepresentation of information may result in denial of service. *

  23. If this application has been completed by someone other than the person requesting certification, provide the following information:

  24. Leave This Blank:

  25. This field is not part of the form submission.