APPLICATION FOR ADA DIAL-A-RIDE SERVICE

APPLICATION FOR ADA DIAL-A-RIDE SERVICE

All questions with an * require an answer.

Please select one: * New Application Renew

Part 1

General Information About Applicant:

First Name: *

Last Name: *

MI:

Email Address:

Street Address: *

Apt./#:

City: *

State: *

Zip Code: *

Date of Birth: * Example: 01/25/1932

Home Phone: * Example: 123-456-7890

Mobile Phone: Example : 123-456-7890

Mailing Address (If different from above):

Address:

City:

State:

Zip Code:

Please give us the name and telephone number of someone we can call in an emergency.

First Name: *

Last Name: *

Phone: * Example: 123-456-7890

Relationship: *

Did someone help you fill out this application? * Yes
No

First Name: *

Last Name: *

Phone: * Example: 123-456-7890

Relationship: *

Part 6

Release of Information

By signing this form by electronic signature I understand I am giving consent for Riverside Transit Agency to use and disclose my protected health information for the following purpose and activities:

(1) To transfer information to medical professionals for review, transportation providers and mobility services.
(2) Permission to contact my healthcare provider to verify my disability and treatment plan for purposes of paratransit eligibility.
(3) The information provided is true and correct to the best of my knowledge. I understand that falsification of information will result in denial of service.

RTA appreciates your cooperation in this process and assures you that your protected health information will be managed strictly confidential.

I have read and understand the above statement. * I accept

Name: *

(or Legal Guardians Name if under 18 years old)