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Medical Verification (To be completed by a LICENSED PHYSICIAN)

Please note: United States Department of Transportation ADA regulations permit the requirement of medical certifica- tion in determining ADA paratransit eligibility. Although not mandatory, medical verification will ensure accurate determination of your disability.

The Americans with Disabilities Act of 1990 (ADA) requires that Palm Beach County provide a “paratransit” service to anyone who cannot use Palm Tran fixed-route bus service because of a disability. Paratransit service are provided in an area parallel to Palm Tran fixed-route bus service. The applicant who has asked you to review and sign this form is applying to Palm Tran CONNECTION to be considered eligible for the paratransit service. ADA shared-ride serv- ice is intended only for those trips that the person cannot make using Palm Tran fixed-route buses.

This application form is intended to determine when and under what circumstances the applicant can use Palm Tran fixed-route bus service and when they require shared-ride service.

Signature

__________________________________________________________Date

______________

Please carefully review the information provided by the applicant in Parts 2-4 of this form and then answer the questions below.

1. Please describe all conditions (physical, cognitive, emotional, other) which functionally prevent the applicant from using Palm Tran fixed-route bus service.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. How does this condition PREVENT the applicant from using Palm Tran fixed-

route bus service? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. To the best of your professional knowledge, is the information provided by the applicant in Parts 2-4 of this application true and correct

Yes

No

Do Not Know

S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P r i n t N a m e a n d T i t l e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S t a t e o f F l o r i d a L i c e n s e # : _ _ Telephone #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ B u s i n e s s A d d r e s s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ C i t y / S t a t e / Z i p : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __________________________________________________________

For more information: Palm Tran CONNECTION (561) 649-9838 or (561) 649-0683 (TDD) This document will be made available in an alternative format upon request

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