Colorado Statewide Transit Plan Open House Presentation Fall 2013
Therideapplication 130123094112-phpapp01
1. Dear RIDE Applicant:
Thank you for your interest in THE RIDE, the MBTA’s shared-ride, door-to-
door transportation program for persons who are prevented from
independently using the fixed-route services such as buses, subway trains,
and trolleys (not including commuter rail and boat) due to barriers in
combination with their disability(ies) for some or all trips.
Please have the application fully completed by you and your
licensed/certified human services or health care provider prior to returning it
to us. All information provided is confidential and serves to determine
eligibility only.
Sincerely,
Office for Transportation Access—THE RIDE
Program
Visit our website for more information about THE RIDE at www.mbta.com,
and then navigate to “Riding the T—Accessible Services—THE RIDE”. If
you have any further questions or require an accommodation, please call
the Office for Transportation Access—THE RIDE Program, at 617-222-5123
(Voice), 800-533-6282 (Toll-free Voice), 617-222-5415 (TTY), or email
theride@mbta.com. We look forward to ensuring that public transportation
is available for persons of all abilities.
INSTRUCTIONS PAGE 1
2. INSTRUCTIONS FOR THE RIDE APPLICATION
Please complete each section. If there are questions that you do not
understand, please do not hesitate to call 617-222-5123 or email
theride@mbta.com.
The purpose of this application is to identify the functional limitations and
barriers which prevent you from independently
using MBTA fixed route services buses, subway trains, and trolleys (not
including commuter rail and boat) some or all of the time. It is important that
you and your licensed/certified human services or health care provider
supply specific, detailed responses so we may understand your abilities and
assess your eligibility.
• You, the applicant, should complete pages 1 through 7 of the application.
• A licensed/certified human services or health care provider only needs to
complete ONE Provider Verification Form: A-General Medical, B-Visual
Impairment, C-Epilepsy or Seizure Disorder, D-Cognitive or Mental Health
disabilities. It is optional to submit additional completed verification forms
if applicable.
• Examples of professionals include: Medical Doctor, Psychiatrist,
Psychologist, Social Worker (LSW, LCSW, LICSW), Rehabilitation
Professional, Physical/Occupational Therapist, Certified Orientation and
Mobility Specialist (COMS), Physicians Assistant, Nurse Practitioner, and
Registered Nurse.
• Please attach any documentation that should be considered as part of the
application for Paratransit eligibility.
• When application is fully complete, please mail signed original to:
MBTA Office for Transportation Access/ THE RIDE
Ten Park Plaza, Room 5750, Boston, MA 02116
INSTRUCTIONS PAGE 2
3. ELIGIBILITY CRITERIA
The RIDE adheres to the American with Disabilities Act (ADA) of 1990
eligibility standards for paratransit services. The law is specific in defining
eligibility for ADA complementary paratransit services. A person must have
a physical, cognitive or mental limitation, which prohibits his/her
independent use of accessible fixed route public transportation.
Category 1 Individuals who, as the result of a physical (including visual
impairments), mental, or emotional impairment, and without the assistance
of another individual (except the operator), cannot board, ride, or disembark
from an accessible vehicle some or all of the time.
Category 2 An individual who can independently use an accessible
vehicle, but none is available on his/her route some or all of the time
Category 3 Individuals who have a specific-impairment related
condition that prevents getting to/from a stop within the service area
some or all of the time.
Eligibility criteria does not include: Age, lack of service in your town,
beyond ¾ miles from fixed route services, inconvenience, discomfort,
financial status, or ability to drive. A diagnosis of a potentially limiting illness
or condition is not sufficient; you and your provider must describe how your
disability prevents you from getting to, boarding/disembarking, and/or
riding on fixed route transit services independently.
When completing your application, assess your potential travel throughout
the entire bus and/or rail system during all seasons, not just those in your
immediate neighborhood or those that you normally use.
INSTRUCTIONS PAGE 3
4. APPROVED CATEGORIES OF ELIGIBILITY
Once determined eligible for the MBTA RIDE Paratransit service you
will be assigned an eligibility category. The eligibility category is
consistent with your ability to use fixed route transit. These categories
include:
Unconditional - Individual is not able to use accessible fixed route
transit under any circumstances and is eligible for all trips on the
paratransit service
Conditional - Individual is not able to use accessible fixed route transit in
specific circumstances and is eligible to use the paratransit service under
limited circumstances identified. For example, conditional categories
include:
• Night: Individual is eligible for service from dusk to dawn.
• Heat: Individual is eligible for service when temperatures are above
80 degrees.
• Cold: Individual is eligible for service when temperatures are below
35 degrees.
• Snow/ice: Individual is eligible for service when snow or ice is
present.
• PCA Always: Individual is required to travel with a personal care
attendant for safety.
• Met on Both Ends: Individual is required to be met by someone at
pickup/drop-off locations for safety.
Temporary - Individual is not able to use accessible fixed route (bus, train,
trolley) transit at this time, however the condition or circumstance(s) leading
to eligibility is reasonably expected to improve in the future.
INSTRUCTIONS PAGE 4
5. APPLICATION SUBMISSION
Once your application is received, the Eligibility Review Committee will
review it. After the eligibility determination is made, we will notify you in
writing. Please allow 21 days from the day we receive your completed
application for processing.
Call the Office for Transportation Access if you have any questions about
the decision. If your eligibility determination has not been made within 21
days of receipt of your completed application, you will be granted THE RIDE
service until the determination is made.
If you have any questions about the application or you want to check the
status of your application, contact the Office for Transportation Access at
800-533-6282 (Toll-free Voice),
617-222-5123 (Voice), or 617-222-5415 (TTY) for the deaf and hard of
hearing.
ABOUT THE RIDE SERVICE
The MBTA's paratransit service, THE RIDE, provides advance notice,
shared-ride, door-to-door transportation to those who, because of a mental,
physical or cognitive disability, are unable
to use fixed-route public transportation.
As a customer of this shared-ride service, you will travel with other
passengers on vehicles that operate within a 60 city and town service area.
(See enclosed listing of communities). Greater detail on use of the service
will be provided upon completion of the registration process.
INSTRUCTIONS PAGE 5
6. ADDITIONAL MBTA RESOURCES AND CONTACTS
• Visit www.mbta.com for transit updates, accessibility, and travel
information
• Call our Customer Communications Center at
800-392-6100 (Toll-free Voice), 617-222-3200 (Voice),
or 617-222-5146 (TTY) for accessibility related questions concerning
MBTA buses, subway, commuter trains or boats, or for travel
information.
• MBTA Senior and Access Program Information
o www.mbta.com Riding the T Accessible Services Reduced Fare
CharlieCard (buses, subways and trains, commuter rail and
boat) for seniors and persons with disabilities are available at
Back Bay Station on the Orange Line. For information, call 800-
543-8287 (Toll-free voice), 617-222-5438 (Voice), 617-222-5854
(TTY).
• Elevator / Escalator Update Line
o 800-392-6100, press 6 or www.mbta.com ‘Rider Tools’
o 617-222-2828 (Voice), 617-222-5854 (TTY),
Mon. - Fri., 8:30 a.m. - 5:00 p.m.
• The Access Advisory Committee to the MBTA (AACT) is a consumer
body that advises and makes recommendations to the MBTA
regarding accessible transportation. Anyone is invited to participate.
The goal of AACT is to achieve 100% accessible transportation.
AACT meets monthly at the State Transportation Building, 10 Park
Plaza in Boston. For meeting information or to be placed on their
mailing list call 617-973-7507(Voice), 617-973-7089 (TTY) or email
aact@ctps.org.
INSTRUCTIONS PAGE 6
7. CITIES AND TOWNS IN THE MBTA SERVICE AREA
Boston North
GLSS
Northwest
VTS
South
JV
Allston Beverly Arlington Boston
Back Bay Boston Bedford Braintree
Brighton Chelsea Belmont Canton
Charlestown Danvers Boston Cohasset
Chinatown Everett Brookline Dedham
Dorchester Lynn Burlington Dover
Downtown
Boston
Lynnfield Cambridge Hingham
East Boston Malden Concord Holbrook
Fenway Marblehead Lexington Hull
Hyde Park Melrose Lincoln Medfield
Jamaica Plain Middleton Medford Milton
Mattapan Nahant Newton Needham
North End Peabody Somerville Norwood
Roslindale Reading Waltham Quincy
Roxbury Revere Watertown Randolph
South Boston Salem Weston Sharon
South End Saugus Wilmington Walpole
West Roxbury Stoneham Winchester Wellesley
Swampscott Woburn Westwood
Topsfield Weymouth
Wakefield
Wenham
Winthrop
For information on Massachusetts cities and towns not serviced by THE
RIDE program, visit massdot.state.ma.us/Transit and navigate to Regional
Transit link, or call 617-973-7000 (Voice) or 617-973-7306 (TTY). Service
availability, hours of service, fares and policies vary in other areas.
INSTRUCTIONS PAGE 7
9. THE RIDE
Paratransit Eligibility Application
Send original (not fax or copy) to:
MBTA Office for Transportation Access
Ten Park Plaza, Room 5750
Boston, MA 02116
Questions? Contact us at:
theride@mbta.com
800-533-6282, 617-222-5123(V)
617-222-5415(TTY)
I. GENERAL INFORMATION: PLEASE TYPE/PRINT CLEARLY
Male
Applicant Name _________________________________________ Female
First Middle Initial Last
Home Address________________________________________ Apt. _______
City __________________________ State________ Zipcode_________
Email ___________________________________Date of birth____ /____ /____
Voice Voice Voice
Phone ____________ TTY ____________ TTY______________ TTY
Home Work Cell
Mailing address __________________________________ Apt.________
(if different than above)
City ____________________________ State________ Zip code_________
Email _____________________________________________________________
Emergency contact:
Name _____________________________ Relationship to you______________
Voice Voice Voice
Phone ______________ TTY _______________ TTY _____________ TTY
Home Work Cell
Preferred format for materials from us? Large Print Braille Other
Audio CD Email/electronic
RIDE APPLICATION PAGE 1
MBTA Use Only
I.D. #:_____________________
Date:_____________________
10. II. MOBILITY AID, DISABILITY, AND MEDICAL INFORMATION
1. Will you be traveling with a personal care assistant (PCA)?
Yes, at all times No Sometimes
Note: PCAs are not provided by the MBTA or RIDE contractors, but we will provide
space on the vehicle for your PCA.
2. Do you use a mobility aid or device? Yes No
a. If yes, which mobility aids or equipment do you use? (check all that apply)
Manual wheelchair Walker Powered scooter
Powered wheelchair Cane Guide/White cane
Prosthetic device/brace Crutches Oxygen tank
Service animal (guide dog, etc.) Describe:______________________
Other, please specify:______________________________________
b. Is your scooter/wheelchair wider than 30”?
Yes No I don’t know Not applicable
c. Is your scooter/wheelchair longer than 48”?
Yes No I don’t know Not applicable
d. Is the combined weight of you & your mobility device more than 650 lbs?
Yes No I don’t know Not applicable
3. Are you currently receiving a treatment/therapy that affects your functional
ability to independently use the MBTA fixed route services?
Yes No
If yes, which treatments are you receiving, and for how long?
Treatment_______________________Duration__________________________
Treatment_______________________Duration__________________________
RIDE APPLICATION PAGE 2
11. 4. Please identify all conditions that prevent you from independently using MBTA
fixed-route services such as buses, trolleys, subway trains (not including
commuter rail) some or all of the time.
Neuromuscular:
Arthritis
Cerebral Palsy
Multiple Sclerosis
Muscular Dystrophy
Parkinson’s Disease
Paraplegia
Quadriplegia
Stroke/Cerebral
Trauma (Date of
occurrence)________
Other:_____________
Medical:
Cancer
Cognitive (D)
Diabetes
Epilepsy/Seizure
Disorder (C)
Hearing Impairment
HIV/AIDS
Kidney Disease/Dialysis
Lupus
Mental Health (D)
Surgery (Date)_______
Visual Impairment (B)
Other:_____________
Cardiovascular:
Arteriosclerosis
Asthma
Chronic Obstructive
Pulmonary Disease
Congestive Heart Failure
Cystic Fibrosis
Emphysema
Heart Attack
Peripheral Vascular
Disease
Thrombosis
Other:_______________
A licensed/certified human services or health care provider only needs to
complete ONE Provider Verification Form: A-General Medical, B-Visual
Impairment, C-Epilepsy or Seizure Disorders, D-Cognitive or Mental Health
disabilities. It is optional to submit additional completed verification forms if you
want to provide more information.
5. Is your functional limitation permanent? Yes No
If No, what is the expected duration?
# of Months______ # of Years______ Unsure ______
RIDE APPLICATION PAGE 3
12. III. FUNCTIONAL ABILITIES AND MOBILITY
6. Can you, with your mobility device (if applicable):
a. Independently ask for and understand written or spoken directions?
Yes No Sometimes (Explain)_________________________
b. Independently cross the street?
Yes No Sometimes (Explain)_________________________
c. Independently wait for 10 minutes without a bench or seating area?
Yes No Sometimes (Explain)_________________________
d. Independently step on and off a sidewalk from a curb?
Yes No Sometimes (Explain)_________________________
e. Independently board an MBTA bus or subway train if it has a
lift/ramp/kneeler? (All buses are 100% accessible.)
Yes No Sometimes (Explain)_________________________
f. Independently walk up and down a flight of stairs if there is a handrail?
Yes No Sometimes (Explain)_________________________
g. Independently stand on a moving bus or subway train holding onto a
handrail?
Yes No Sometimes (Explain)_________________________
h. Independently transfer from one bus or subway train to another?
Yes No Sometimes (Explain)_________________________
i. Independently recognize when it’s time to get on/off the bus/rail vehicle?
Yes No Sometimes (Explain)_________________________
j. Independently safely travel through crowded and/or complex MBTA
facilities?
Yes No Sometimes (Explain)_________________________
RIDE APPLICATION PAGE 4
13. 7. How does your disability prevent independent use of the MBTA fixed route
services?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
8. To the best of your knowledge, under optimal conditions, approximately how
far can you independently walk/travel outdoors? (with mobility aid if used)
Less than one block
1-2 blocks (1/4 mile)
4 blocks (1/2 mile)
6 blocks (3/4 mile)
8 blocks (1 mile)
I cannot travel alone outdoors
Please specify optimal conditions:____________________________________
9. What are the barriers in your environment that combined with your disability,
prevent you from using the MBTA independently? Some examples may
include:
Busy street to cross Steep hills Time of day
Lack of curb cuts No crosswalk light Snow/Ice
Construction
No sidewalk/Sidewalk condition (Describe): _________________________
Other_________________________________________________________
10.Is your condition affected by weather? Yes No
If yes, please explain:______________________________________________
________________________________________________________________
RIDE APPLICATION PAGE 5
14. 11.Which of the following best describes your use of MBTA fixed-route services,
such as buses and subway trains?
I’ve never used the MBTA
I’ve used the MBTA, but not since the onset of my disability:
0-1 years ago 1-5 years ago over 5 years ago
I currently use the MBTA system:
Rarely sometimes/ occasionally frequently / all the time
12.Please explain your experiences/challenges/observations with MBTA fixed-
route services?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
13.Have you ever received travel training to use the MBTA fixed route system
(bus, trolley, train)? Yes No
If yes, when?_____________________________________________________
Did you complete the training? Yes No
14.If you currently do not use the MBTA fixed-route services, is there anything
that might help you to do so? (Check all that apply)
Mobility Device Route/Schedule Information
Communication Aid Other_________________________
Orientation & Mobility Instruction or Travel Training
15.Which best describes your current living situation?
Skilled nursing facility Assisted living facility Group home
Other:____________ House, apartment Rehab hospital
RIDE APPLICATION PAGE 6
15. 16. Provide any additional information that explains your functional level of
mobility or the barriers/conditions that prevent you from using fixed route
services. (Attach as much documentation as you need)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
RIDE APPLICATION PAGE 7
16. Sign below to indicate that the information you have given is correct to the best
of your knowledge. If you are unable to sign, you may have someone sign for
you and indicate their relationship to you.
I understand that the purpose of this application is to determine if there are
times when I cannot use MBTA fixed-routes, such as buses and subway
trains, and must therefore use ADA Paratransit services. I certify, to the
best of my knowledge, that the information in this application is true and
correct. I understand that providing false or misleading information may
result in a reevaluation or revocation of my eligibility.
X_______________________________ Date ____________
Applicant's Signature
Sign below to indicate permission for your health provider to release
information for the sole purpose of facilitating your eligibility determination or
providing you with transportation. If you are unable to sign, you may have
someone sign for you and indicate their relationship to you.
I hereby authorize my Human Service or Health Care Provider to release any
information necessary to determine RIDE eligibility to the MBTA.
X_______________________________ Date ____________
Applicant's Signature
Applicant’s Checklist:
There is a signature and date in both spaces above.
My completed portion of the application, with the appropriate Provider’s
Verification Form, has been given to my human service or health care
provider.
The Provider’s Verification Forms A-General Medical, B-Visual
Impairment, C-Epilepsy & Seizure Disorder, and/or D-Mental Health or
Cognitive, are complete.
RIDE APPLICATION PAGE 8
STOPNEXT SECTION TO BE COMPLETED BY LICENSED/CERTIFIED
HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY
17. MBTA RIDE GENERAL MEDICAL FORM A
THE RIDE PARATRANSIT ELIGIBILITY APPLICATION
TO BE COMPLETED BY LICENSED/CERTIFIED
HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY
By completing and signing this document, you the health care professional,
certify the truth and accuracy of the information provided on this application, to
the best of your professional knowledge. The American with Disabilities Act of
1990 requires that the MBTA provide services to persons who are unable to use
the fixed-route system (such as buses, trolleys, subway trains, not including
commuter rail and boat) due to a disability. The information you provide will
allow the MBTA to make an appropriate evaluation of eligibility. To qualify for
Paratransit service, an individual must meet at least one of the following criteria:
Category 1 Individuals who, as a result of a physical or mental
impairment (including visual impairments), and without the assistance of
another individual (except the operator) cannot board, ride, or disembark
from an accessible transit vehicle.
Category 2 Individuals who can independently use accessible vehicles, but
none are available on their route.
Category 3 Individuals who have a specific-impairment related condition
that prevents them from independently getting to/from a stop.
A licensed/certified human services or health care provider only needs to
complete ONE Provider Verification Form: A-General Medical, B-Visual
Impairment, C-Seizure or Epilepsy Disorders, D-Cognitive or Mental Health
disabilities. It is optional to submit additional completed verification forms if you
want to provide more information.
Information which you provide will assist us in determining the applicant's
functional ability to use public transportation. It is essential that you be precise
and comprehensive. False or misleading information diverts resources away from
persons legitimately qualified to use this program.
18. THE RIDE Paratransit Eligibility Form A:
Licensed Provider’s Form (General Medical)
Applicant’s Name:________________________________Date of Birth: _______
Applicant’s Address:_________________________________________________
Relationship to the applicant: _________________________________________
How long have you provided services/treatment for the applicant?___________
1. What is the medical condition that prevents applicant from accessing,
boarding, disembarking, and/or riding on the MBTA independently? (Note:
MBTA fixed-route buses are 100% accessible. Eligibility criteria does not
include age, inability to drive or that service would “benefit” the applicant.)
________________________________________________________________
2. Date of onset?____________________________________________________
3. How does the applicant’s disability in combination with any barriers in the
environment, prevent the applicant from independent use of the MBTA fixed
route services? ___________________________________________________
________________________________________________________________
4. Does the applicant have the ability to travel in complex, crowded stations?
Consider the station, time of day, accessibility of the station, etc.
Yes No Sometimes
If no or sometimes, please explain: __________________________________
________________________________________________________________
5. Is the applicant’s functional limitation permanent? Yes No
If no, what is the expected duration?
# of Months______ # of Years ______ Unsure ______
6. For safety reasons, should the applicant travel (on THE RIDE) at all times with
a personal care attendant (PCA)? Yes No
If yes, please
explain._________________________________________________________
________________________________________________________________
MBTA RIDE GENERAL MEDICAL FORM A P1
19. 7. For safety reasons can the applicant be left unattended at pickup or drop-off
locations? Yes No
If no, please explain_______________________________________________
________________________________________________________________
8. Do you agree with the applicant’s self assessment on pages 1-7? Yes No
If no, please explain ______________________________________________
________________________________________________________________
________________________________________________________________
9. Is there any additional information about conditions/barriers that prevent
the applicant from using the fixed route some or all of the time
________________________________________________________________
10. Provider’s Checklist:
I have provided a live signature (not photocopied, or stamped)
I have completed all contact info below, including a State Board
License # or Certification # ( not NPI, DEA).
I certify that the information given above is correct to the best of my knowledge.
X______________________________________________________
Signature of Licensed Health Care or Human Service Provider
Clearly print your contact info below:
CERT # or
NAME___________________________________BOARD LIC#_____DATE______
PHONE #_________________________________FAX # ____________________
BUSINESS ADDRESS _________________________________________________
EMAIL ____________________________________________________________
When application is fully complete, please mail signed original to:
MBTA Office for Transportation Access/ THE RIDE
Ten Park Plaza, Room 5750, Boston, Massachusetts 02116
THANK YOU FOR YOUR TIME AND INPUT.
MBTA RIDE GENERAL MEDICAL FORM A P2
21. MBTA RIDE VISION FORM B
THE RIDE PARATRANSIT ELIGIBILITY APPLICATION
TO BE COMPLETED BY LICENSED/CERTIFIED
HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY
By completing and signing this document, you the health care professional, certify
the truth and accuracy of the information provided on this application, to the best of
your professional knowledge. The American with Disabilities Act of 1990 requires
that the MBTA provide services to persons who are unable to use the fixed-route
system (such as buses, trolleys, subway trains, not including commuter rail and boat)
due to a disability. The information you provide will allow the MBTA to make an
appropriate evaluation of eligibility. To qualify for Paratransit service, an individual
must meet at least one of the following criteria:
Category 1 Individuals who, as a result of a physical or mental impairment
(including visual impairments), and without the assistance of another individual
(except the operator) cannot board, ride, or disembark from an accessible
transit vehicle.
Category 2 Individuals who can independently use accessible vehicles, but
none are available on their route.
Category 3 Individuals who have a specific-impairment related condition
that prevents them from independently getting to/from a stop.
A licensed/certified human services or health care provider only needs to complete
ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizure
or Epilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional to
submit additional completed verification forms if you want to provide more
information.
Information which you provide will assist us in determining the applicant's
functional ability to use public transportation. It is essential that you be precise and
comprehensive. False or misleading information diverts resources away from
persons legitimately qualified to use this program.
22. THE RIDE Paratransit Eligibility Form B:
Licensed or Certified OMS Provider’s Verification Form (Visual Impairment)
Applicant’s Name:______________________________Date of Birth:____________
Applicant’s Address: ___________________________________________________
Relationship to the applicant:____________________________________________
How long have you provided services/treatment for the applicant? _____________
1. Please specify the applicant’s Visual Impairment:__________________________
2. Date of onset _______________________________________________________
3. Is applicant’s functional limitation permanent? Yes No
If no, what is the expected duration?
# of months______ # of years______ unknown______
4. What is the prognosis? _______________________________________________
5. Please note mobility aids used by applicant:______________________________
6. Has the applicant received travel training to use the MBTA fixed route system
(buses, trolleys, trains)? Yes No unknown
If yes, what were the outcomes?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
7. How does the applicant’s disability, combined with any environmental barriers,
prevent independent use of the MBTA fixed route services? (i.e. buses, trolleys,
trains) ____________________________________________________________
__________________________________________________________________
__________________________________________________________________
8. Please comment on the applicant’s ability to perform the following tasks:
• Independently use a mobility aid
____________________________________________________________________
• Independently cross streets/intersections
____________________________________________________________________
• Independently travel in various conditions (lighting, weather, background noise)
____________________________________________________________________
• Independently navigate paths of travel, inclines, uneven terrain
____________________________________________________________________
MBTA RIDE VISION FORM B P1
23. • Independently orient oneself to surroundings, and plan or follow a route
___________________________________________________________________
• Independently detect stations/stops
___________________________________________________________________
• Independently navigate curbs/steps w/mobility device (if applicable)
___________________________________________________________________
9. For safety reasons should, the applicant travel (on THE RIDE) at all times with a
personal care attendant (PCA)? Yes No
If yes, please explain _______________________________________________
_________________________________________________________________
10.For safety reasons is the applicant able to be left unattended at pickup or drop-
off locations? Yes No
If no, please explain _______________________________________________
________________________________________________________________
11.Any additional information about conditions/barriers that prevent the applicant
from using the fixed route some or all of the time ______________________
________________________________________________________________
12.Provider’s Checklist:
I have provided a live signature (not photocopied, or stamped)
I have completed all contact info below, including a State Board License # or
Certification # (not NPI, DEA).
I certify that the information given above is correct to the best of my knowledge.
X____________________________________________________
Signature of Licensed Health Care or Human Service Provider
Clearly print your contact info below: CERT # or
NAME_____________________________STATE BOARD LIC#______DATE _______
PHONE #______________________________FAX # _________________________
BUSINESS ADDRESS____________________________________________________
EMAIL ______________________________________________________________
When application is fully complete, please mail signed original to:
MBTA Office for Transportation Access/ THE RIDE
Ten Park Plaza, Room 5750, Boston, Massachusetts 02116
MBTA RIDE VISION FORM B P2
25. MBTA RIDE EPILEPSY/SEIZURE DISORDER FORM C
THE RIDE PARATRANSIT ELIGIBILITY APPLICATION
TO BE COMPLETED BY LICENSED/CERTIFIED
HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY
By completing and signing this document, you the health care professional, certify
the truth and accuracy of the information provided on this application, to the best of
your professional knowledge. The American with Disabilities Act of 1990 requires
that the MBTA provide services to persons who are unable to use the fixed-route
system (such as buses, trolleys, subway trains, not including commuter rail and boat)
due to a disability. The information you provide will allow the MBTA to make an
appropriate evaluation of eligibility. To qualify for Paratransit service, an individual
must meet at least one of the following criteria:
Category 1 Individuals who, as a result of a physical or mental impairment
(including visual impairments), and without the assistance of another individual
(except the operator) cannot board, ride, or disembark from an accessible transit
vehicle.
Category 2 Individuals who can independently use accessible vehicles, but none
are available on their route.
Category 3 Individuals who have a specific-impairment related condition
that prevents them from independently getting to/from a stop.
A licensed/certified human services or health care provider only needs to complete
ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Epilepsy
or Seizure Disorder, D-Cognitive or Mental Health disabilities. It is optional to submit
additional completed verification forms if you want to provide more information.
Information which you provide will assist us in determining the applicant's functional
ability to use public transportation. It is essential that you be precise and
comprehensive. False or misleading information diverts resources away from persons
legitimately qualified to use this program.
26. THE RIDE Paratransit Eligibility Form C:
Licensed Provider’s Verification Form (Epilepsy or Seizure Disorder)
Applicant’s Name:________________________________Date of Birth: ___________
Applicant’s Address:_____________________________________________________
Relationship to the applicant: _____________________________________________
How long have you provided services/treatment for the applicant?_______________
1. Type of Seizure: ____________________________________________________
2. Seizure Frequency: __________________________________________________
3. Does the seizure alter consciousness or awareness? Yes No
4. Are the seizures preceded by an aura? Yes No
5. Are there any triggers to the seizures? Yes No
If yes, what are they? _______________________________________________
__________________________________________________________________
6. What behaviors are exhibited during/following the applicant’s seizure?
__________________________________________________________________
__________________________________________________________________
7. Is the applicant taking prescribed seizure medications that affect functional
ability to independently use the MBTA fixed route services (bus, trolley, train)?
Yes No
If yes, please note the effects of the medication.
__________________________________________________________________
__________________________________________________________________
8. Is the applicant’s functional limitation permanent? Yes No
If no, what is expected duration?
# of Months_____ # of Years_____ unknown_____
9. What advice or limitations on independent travel have you communicated to
the applicant?______________________________________________________
__________________________________________________________________
10.For safety reasons should the applicant travel (on THE RIDE) at all times with a
personal care attendant (PCA)? Yes No
If yes, please explain ________________________________________________
__________________________________________________________________
MBTA RIDE EPILEPSY/SEIZURE FORM C P1
27. 11. For safety reasons can the applicant be left unattended at pickup or drop-off
locations? Yes No
If no, please explain_________________________________________________
__________________________________________________________________
12. Please provide any additional information on the applicant’s ability to travel
independently on the MBTA fixed route services._________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
13. Provider’s Checklist:
I have provided a live signature (not photocopied, or stamped)
I have completed all contact info below including a State Board License # Or
Certification # (not NPI, DEA).
I certify that the information given above is correct to the best of my knowledge.
X____________________________________________________
Signature of Licensed Health Care or Human Service Provider
Clearly print your contact info below:
CERT # or
NAME_______________________________STATE BOARD LIC#________DATE______
PHONE #______________________________FAX # ___________________________
BUSINESS ADDRESS______________________________________________________
EMAIL ________________________________________________________________
When application is fully complete, please mail signed original to:
MBTA Office for Transportation Access/ THE RIDE
Ten Park Plaza, Room 5750, Boston, Massachusetts 02116
THANK YOU FOR YOUR TIME AND INPUT.
MBTA RIDE EPILEPSY/SEIZURE FORM C P2
29. MBTA RIDE COGN/MH FORM D
THE RIDE PARATRANSIT ELIGIBILITY APPLICATION
TO BE COMPLETED BY LICENSED/CERTIFIED
HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY
By completing and signing this document, you the health care professional, certify
the truth and accuracy of the information provided on this application, to the best of
your professional knowledge. The American with Disabilities Act of 1990 requires
that the MBTA provide services to persons who are unable to use the fixed-route
system (such as buses, trolleys, subway trains, not including commuter rail and boat)
due to a disability. The information you provide will allow the MBTA to make an
appropriate evaluation of eligibility. To qualify for Paratransit service, an individual
must meet at least one of the following criteria:
Category 1 Individuals who, as a result of a physical or mental impairment
(including visual impairments), and without the assistance of another individual
(except the operator) cannot board, ride, or disembark from an accessible transit
vehicle.
Category 2 Individuals who can independently use accessible vehicles, but none
are available on their route.
Category 3 Individuals who have a specific-impairment related condition
that prevents them from independently getting to/from a stop.
A licensed/certified human services or health care provider only needs to complete
ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizure or
Epilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional to submit
additional completed verification forms if you want to provide more information.
Information which you provide will assist us in determining the applicant's functional
ability to use public transportation. It is essential that you be precise and
comprehensive. False or misleading information diverts resources away from persons
legitimately qualified to use this program.
30. THE RIDE Paratransit Eligibility Form D:
Licensed Provider’s Verification Form (Cognitive or Mental Health Conditions)
Applicant’s Name: ________________________________ Date of Birth:___________
Applicant’s Address: _____________________________________________________
Relationship to the applicant:______________________________________________
How long have you provided services/treatment for the applicant?________________
1. What is the applicant’s diagnosis (DSM-IV)? ______________________________
2. Date of onset? ______________________________________________________
3. What is the prognosis? _______________________________________________
4. Is the applicant taking medications related to this disability that affect functional
ability to independently use the MBTA fixe route services? Yes No
a. If yes, please describe the effects of the medication.
___________________________________________________________________
___________________________________________________________________
5. Is the applicant receiving treatment/therapy that affect functional ability to
independently use the MBTA fixed route services? Yes No
a. If yes, please specify treatment/therapy and indicate an expected duration.
Treatment_________________________Duration__________________________
Treatment_________________________Duration__________________________
6. Is the applicant’s disability the same every day? Yes No
a. If no, please explain ________________________________________________
__________________________________________________________________
__________________________________________________________________
7. Are any of the following affected by the individual’s disability? Check all that
apply.
_____Orientation _____Concentration _____Monitoring time
_____Problem-solving _____Coping Skills _____Judgement
_____Short term memory _____Communication _____Gait or balance
_____Long term memory _____Consistency _____ Social behavior
_____Aggression _____Performance
_____Other __________________________________________________________
MBTA RIDE COGN/MH FORM D P1
31. 8. Please explain how the above interferes with safe travel?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9. Describe how the applicant’s disability affects his/her ability to independently
complete the following travel tasks:
• Orient oneself to environment ________________________________________
• Travel alone outside _________________________________________________
• Leave the house on time _____________________________________________
• Seek and act on directions ____________________________________________
• Find way to/from bus stop or station ___________________________________
• Cross streets _______________________________________________________
• Wait for a bus or subway train _________________________________________
• Board correct bus or subway train ______________________________________
• Ride on a bus or train ________________________________________________
• Transfer to a second bus or train or exit at the correct destination
__________________________________________________________________
• Understand time and follow a schedule__________________________________
• Know when he/she is lost_____________________________________________
• Get help if he/she is lost______________________________________________
• Recognize and avoid dangers __________________________________________
10. Please provide information on how the applicant’s disability, combined with
any environmental barriers, prevent independent use of the MBTA fixed route
services? (bus, trolley, train)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MBTA RIDE COGN/MH FORM D P2
32. 11. For safety reasons should the applicant travel (on THE RIDE) at all times with
a personal care attendant (PCA)? Yes No
If yes, please explain.__________________________________________________
____________________________________________________________________
____________________________________________________________________
12. For safety reasons is the applicant able to be left unattended at pickup or
drop-off locations? Yes No
If no, please explain___________________________________________________
____________________________________________________________________
13. Is there any other information that would be an indication of the applicant’s
inability to independently use fixed-route public transportation?
____________________________________________________________________
____________________________________________________________________
14. Provider’s Checklist:
I have provided a live signature (not photocopied, or stamped)
I have completed all contact info below including a State Board License # or
Certification # (not NPI, DEA).
I certify that the information given above is correct to the best of my knowledge.
X___________________________________________________
Signature of Licensed Health Care or Human Service Provider
Clearly print your contact info below: CERT # or
NAME_______________________________STATE BOARD LIC#________DATE_______
PHONE #______________________________FAX # ____________________________
BUSINESS ADDRESS_______________________________________________________
EMAIL _________________________________________________________________
When application is fully complete, please mail signed original to:
MBTA Office for Transportation Access/ THE RIDE
Ten Park Plaza, Room 5750, Boston, Massachusetts 02116
THANK YOU FOR YOUR TIME & INPUT. MBTA RIDE COGN/MH FORM D P3
