Renewal Application for ADA Paratransit Eligibility

Applicant information

Please provide the name of a LOCAL relative/friend in case of an emergency

List the disabling health conditions preventing you from using SacRT fixed route bus and light rail services.

Have your existing disability related functional limitations improved, worsened, or remained the same since you were last certified by SacRT Accessible Services? Please explain?

Have you experienced any new disability related functional limitations? Please explain how they limit your use of SacRT buses, SmaRT Ride, and light rail trains?

Is there anything else you want to tell us about your disabling health condition(s)?

Certification of Applicant

I understand the information I provided on this application is true and correct to the best of my knowledge. The purpose of this application is to determine if I am eligible to use ADA paratransit services, or if at times I can ride the SacRT regular buses and light rail trains. I understand that falsification of information could result in a loss of ADA paratransit services as well as a penalty under the law. I also understand that it may be necessary for SacRT Accessible Services:

To contact me with questions they have;
To require that I visit the office for an in-person interview;
To consult a professional familiar with my disabling condition(s) and functional abilities.

I agree to notify SacRT if my condition changes, if my mobility device has been replaced, if I have a new mobility device, or if I no longer need to use ADA paratransit service. I understand that if this form is incomplete or a completed and signed Confidential Authorization for Release of Medical Information form is not included with this application, then both will be returned to me, and I may have to complete a full ADA Paratransit Application instead.

Confidential Authorization for Release of Medical Information

Applicant information

Applicant’s Primary Physician or Health Care Provider/Organization

Physician’s Full Name

Subject to the following terms and conditions, I hereby authorize the above health care provider, the Accessible Services Department of the Sacramento Regional Transit District (“RT”), and others at RT with a need to know, to use and disclose my personal medical information. This information may be used or disclosed only for the following purposes: (1) assess and evaluate my ability to access the fixed route system, and (2) determine my eligibility for ADA complementary paratransit service. Only medical information relevant to the above-referenced purposes may be disclosed.
RIGHT OF REVOCATION: I understand that my personal representative or I may alter or revoke this authorization at any time in writing. I understand this change will not affect information already shared.
EXPIRATION OF AUTHORIZATION: Unless otherwise revoked, this Authorization shall become effective immediately after signed and shall remain in effect for 90 days from the date of this signature.
I understand that I have a right to request a copy of this Authorization for Release of Medical Information.

Signature of Applicant, or Guardian if Applicable or person completing the application as listed above.