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The Metrolift Application form is a document designed for individuals seeking paratransit services through METRO in Houston, Texas. This form collects essential information regarding the applicant's ability to use public transportation and their specific mobility needs. Completing the application accurately is crucial for determining eligibility for METROLift services.

Table of Contents

The METROLift Application form is a crucial document for individuals seeking paratransit services in Houston, Texas. This form is designed to gather essential information about the applicant's mobility needs and their ability to utilize METRO bus services. It spans several pages and requires detailed responses regarding personal information, medical impairments, and functional capacities. The first four pages focus on the applicant's disability, assistive devices, and travel capabilities. It is important to answer all questions thoroughly, as incomplete information may hinder the eligibility determination process. For those needing assistance, a friend, family member, or caregiver can help in completing these sections. Pages five and six require certification from a physician or certified health professional who understands the applicant's condition. This ensures that the information provided is accurate and reliable. Should any questions arise during the application process, applicants are encouraged to contact METROLift Customer Service for support. Completing this form is a vital step toward accessing essential transportation services that promote independence and mobility.

1900 Main

P.O.Box 61429

Houston, TX 77208-1429

Client ID #

Date Entered

Processed by

Application for METROLift Service

Instructions: On pages 1 – 4 of this application, METROLift is asking for information about you and your ability to use METRO bus service. Please take the time to answer ALL questions carefully and completely. A friend, guardian, caregiver, agency service representative or family member may help you complete your portion of the application, pages 1- 4. Accurate information is required about you, your medical impairment, and your functional capacity. Pages 5 - 6 must be completed and certified by a physician/certified health professional who is familiar with your impairment or condition. Both the eligibility form and the doctor's additional signature must be submitted to METROLift for processing. Failure to do so will delay the processing of your application.

If you have questions, please call METROLift Customer Service at 713-225-0119.

Have you ever applied for METROLift?

Yes

TO BE COMPLETED BY APPLICANT

Name of Applicant

Last/Apellido

First/Nombre

Middle/Inicial Nombre de solicitante

Nombre de solicitante

Address/Street / Dirección/Calle

Apartment Number

City/Ciudad

Zip Code/Codigo Postal

Numero de Apatamento

Date of Birth/Fecha de Nacimiento

Home Phone Number/En Casa Número de Teléfono

Other Phone/Otro Teléfono

Apartment Complex Name/Nombre

Gate Code/Codigo de Cochera

de Apartamentos

Mailing Address/Dirección de Envío

City/Ciudad

State/Estado

Zip Code/Codigo Postal

If different from home address/Si diferente de domicilio

Applicant Signature (required)

Firma

Date/Fecha

Name of Emergency Contact/Contacto de Emergencia

Relationship/Relación

Emergency Phone/Numero de Emergencia

Page 1

METRO 0447-17-(06/22)

INDIVIDUAL AND MOBILITY INFORMATION

1.Please state your disability(s).

2.What assistive device(s) do you use when traveling? (Please check all that apply.)

Support Cane	Manual wheelchair	Trained service animal
Crutches	Powered wheelchair	Communications device
Walker	Power scooter	“White cane”
Leg brace(s)	Portable oxygen	None
Other (describe)

3.What is the nearest street intersection to your home? (Example: Polk & Wayside)

4.Can you walk or use your wheelchair or assistive device(s) from your home to that

intersection without assistance?			Yes		No
If “no,” please explain.

5.Can you find your way to a bus stop without getting lost? If "no," please explain.

Yes

6. How long can you stand and wait for a bus?
15 minutes	10 minutes	5 minutes	Less than 5 minutes

7.All buses have a "destination sign" in front, which shows the route name and number.

Can you read a bus destination sign?	Yes	No
Can you ask the driver where the bus is going?	Yes	No
Can you give or write a note to the driver?	Yes	No
Can you understand the driver's answer?	Yes	No
If "no" to any questions, please explain.

METRO 0447-17-(06/22)

Page 2

8. If you were on the bus, could you pay the fare by putting money in the fare box, or by tapping the

METRO Q Card on the Q box?

If “no” please explain

Yes

9.If you were on the bus, could you recognize the place where you wanted to get off the bus?

Yes No

If "no," please explain.

10.Please tell us about the times when you can use METRO’s local fixed-route bus service? (Example: if short distance to bus stop; take attendant; need to get somewhere.)

11.Have you ever received " orientation and mobility training "or " travel training?" Yes If " yes," please list any METRO bus routes on which you can travel:

12.Please tell us the reasons you feel you cannot use METRO’s local fixed-route bus service for some or all trips.

13.How do you currently travel (self, family, friends, bus, rail, METROLift, etc.)? Please explain.

14. Do you require someone to travel with you?	Yes
If "yes," please explain

15.Can you wait independently alone at your residence and places to which you travel?

Yes No

If "no," please explain.

METRO 0447-17-(06/22)

Page 3

AGREEMENT AND AUTHORIZATION:

I state that the information I have provided is true and accurate.

I authorize the release of diagnostic and functional information as requested on pages 5 and 6 to METRO for the sole purpose of making a determination regarding my eligibility for paratransit service (METROLift) and understand that personal and medical information will be kept confidential.

I understand that intentionally providing false or misleading information or refusal to undergo an in-person interview assessment is grounds for denial of METROLift services.

If approved, I agree to follow the rules and guidelines established by METROLift and to promptly inform METROLift of any changes in my residence, phone number and, if applicable, my representative's name and phone number; and any significant change in my condition that would affect my level of mobility.

I understand that failure to follow proper procedures or cooperate with METROLift staff, demonstrating illegal or disruptive behavior or, if my condition at any time poses a direct threat to the health or safety of others, such situations may result in either suspension and/or termination of service.

Applicant’s Signature:

Date:

If someone other than the applicant is preparing this form, please provide the following information about the preparer:

Name: (please print) ________________________________________________

Day Phone: ______________________________ Relationship: ______________

Preparer’s Signature: ______________________ Date: ____________________

METRO 0447-17-(06/22)

Page 4

Patient's Name: (please print) ____________________________________________________

Date of Birth: _____________________ Contact No.: _________________________________

Address: ______________________________________________________________________

Dear Physician or Healthcare Professional:

We need your assistance in determining eligibility for services provided by METROLift to persons with disabilities who are unable to use local bus transportation. We are seeking specific information as to what prevents the person from using METRORail and the METRO bus routes that provide transportation throughout the area. METRO buses are equipped with ramps, lifts, and kneeling features to assist boarding as well as automatic announcements of major stops to help riders know where they are along the route. The Americans with Disabilities Act of 1990, 49 CFR 37.121, Subpart F states– “..each public entity operating a fixed route system shall provide paratransit or other special service to individuals with disabilities that is comparable to the level of service provided to individuals without disabilities who use the fixed route system.” “By complementary, DOT means service for individuals with disabilities who cannot use the fixed route bus system.” The information requested of you in the following sections will be used to help determine the applicant’s METROLift eligibility. It is important that all questions be answered completely and accurately to the best of your knowledge and in accordance with your records. If the information is incomplete or unclear, we may need to contact you for clarification. Thank you for your cooperation.

1.	Have you previously seen this patient?	Yes	No
2.	Please rate (Excellent / Good / Fair / Poor / None / Don’t Know) the applicant in terms of:

a. Upper body strength

b. Lower body strength

c.Coordination

d.Balance

e.Self awareness

f.Independent judgment

g.Sense of direction

h.Ability to understand and follow instructions

i.Verbal communication

j.Written communication

k.Stamina and endurance

Excellent Good Fair Poor None Don’t Know

3.In your opinion, can the applicant travel independently from his/her house to the sidewalk?

5.Assuming the use of a mobility aid, if applicable, and with no major barriers in his/her path, how far can the applicant independently travel without assistance?

less than 1/4 mile

1/4 mile

1/2 mile

3/4 mile

more than 3/4 mile

Page 5

6.Does the applicant’s disability require him/her to travel with another person who provides personal

assistance? Yes No Sometimes

7.Please provide medical diagnoses in layman’s terms to describe the applicant’s primary impairments or disabling conditions.

8.We are seeking specific information as to what prevents your patient from accessing the local bus and rail system.

Is the condition

Permanent or

Temporary (months)

10.

If visually impaired, what is the applicant's best corrected acuity?

(Snellen)? (R)

(L)

Field Restriction: (R)

(L)

Date of Testing:

11.

If cognitively impaired, what is the applicant’s cognitive age, and IQ level?

12.

Is the applicant a wheelchair user?

Yes

If yes, how often

13.

Does the applicant use other mobility aids?

Yes

No If yes, please describe.

PHYSICIAN OR HEALTH CARE PROFESSIONAL’S CERTIFICATION :

I certify that the information I have provided herein is a fair representation of this applicant’s medical impairment or condition and is accurate to the best of my knowledge. I understand that the information provided herein will be used for the sole purpose of determining the applicant’s eligibility for paratransit services. I also agree that METROLift may contact me for clarification of any information I have provided and that I will reply in good faith.

Physician’s/Health Professional’s Full Name

Institution/Facility/Agency Name

Street Address

Suite #

City

State

Zip Code

Medical/Social Worker’s License Number

Telephone #

Fax #

Physician’s/Health Professional’s Signature

Date

***Note: Additional signature of physician/healthcare professional on his/her

letterhead or prescription verifying completion of application is required.

Page 6

↓ Metrolift Application PDF

Fact Name	Details
Application Purpose	The METROLift Application is designed to determine eligibility for METROLift services.
Assistance Allowed	Friends, guardians, or caregivers can help complete the application.
Medical Certification	Pages 5-6 require a physician or certified health professional's certification.
Contact Information	Applicants must provide their home and emergency contact information.
Disability Disclosure	Applicants need to state their disabilities and any assistive devices used.
Eligibility Criteria	The application includes questions about the applicant's mobility and ability to use public transportation.
Legal Compliance	The application adheres to the Americans with Disabilities Act of 1990.
Signature Requirement	The applicant must sign the application to confirm the information is accurate.
Preparer Information	If someone else fills out the form, their information must also be provided.
Confidentiality Assurance	Personal and medical information will be kept confidential by METRO.

Filling out the METROLift Application form is an important step toward accessing necessary transportation services. This process requires careful attention to detail to ensure that all information is complete and accurate. Below are the steps to guide you through the application.

Begin by writing your Name in the designated fields: Last, First, and Middle Initial.
Provide the last four digits of your Social Security Number.
Fill in your Address, including Apartment number, City, and Zip Code.
Enter your Date of Birth.
List your Home Phone Number and any Other Phone numbers.
If applicable, provide your Apartment Complex Name and Gate Code.
Complete your Mailing Address if it differs from your home address, including City, State, and Zip Code.
Sign and date the application in the Applicant Signature section.
Fill in the Name of Emergency Contact, their Relationship to you, and their Emergency Phone Number.
On the next pages, answer questions regarding your disability, assistive devices, and mobility capabilities accurately.
Be prepared to explain any limitations you may have regarding public transportation.
Complete the Agreement and Authorization section, affirming the truthfulness of your information.
If someone else is assisting you with the application, they must fill out their information in the preparer section.
Finally, pages 5 and 6 must be completed and certified by a physician or certified health professional.

Once you have completed the form, ensure that all sections are filled out accurately. It’s crucial to provide clear and precise information, as this will help determine your eligibility for METROLift services. If you have any questions during this process, do not hesitate to reach out to METROLift Customer Service for assistance.

What is the purpose of the METROLift Application form?

The METROLift Application form is designed to gather essential information about your mobility and ability to use METRO bus services. By completing this form, you help METROLift determine your eligibility for paratransit services. It's important to provide accurate details regarding your medical condition and functional capacity, as this information directly impacts your application process.

Who can assist me in completing the application?

You are not alone in this process! A friend, family member, caregiver, or agency representative can help you fill out the application. They can assist you with the first four pages, which focus on your personal information and mobility capabilities. It's a great way to ensure that all necessary details are accurately captured.

What information is required from my physician?

Pages five and six of the application must be completed and certified by a physician or a certified health professional who understands your impairment or condition. This section seeks specific details about your ability to use public transportation. Their insights are crucial for determining your eligibility for METROLift services.

What happens if I provide inaccurate information?

Providing false or misleading information can have serious consequences. If it is discovered that you intentionally gave incorrect details, your application for METROLift services may be denied. It’s vital to ensure that all information is truthful and complete to avoid any issues with your eligibility.

Can I still apply if I have never used METROLift before?

Absolutely! Whether you have used METROLift in the past or this is your first time applying, you are welcome to submit an application. The form asks if you have previously applied, but new applicants are encouraged to provide their information and undergo the eligibility assessment process.

How do I contact METROLift if I have questions?

If you have any questions or need assistance while filling out the application, you can reach out to METROLift Customer Service at 713-225-0119. They are there to help you and can provide guidance on any aspect of the application process.

Incomplete Information: Many applicants fail to provide all required information on pages 1-4. Missing details can delay the processing of your application.
Incorrect Social Security Number: Providing an incorrect Social Security number can lead to complications. Ensure that you only include the last four digits as requested.
Not Seeking Help: Some applicants do not seek assistance from a friend or family member when filling out the form. If you find any part confusing, asking for help can clarify things and improve accuracy.
Skipping Physician Certification: Pages 5-6 require certification by a physician or certified health professional. Neglecting this step can result in your application being considered incomplete.
Failure to Explain Limitations: When answering questions about your ability to navigate or use public transport, failing to explain "no" answers can lead to misunderstandings about your needs.
Ignoring the Agreement Section: Some applicants overlook the agreement and authorization section. This part is crucial, as it confirms that you understand the implications of your application and the importance of providing truthful information.

When applying for METROLift services, several other forms and documents may be required to ensure a complete application process. These documents help provide additional information about your eligibility and needs. Below is a list of commonly used forms alongside the METROLift Application form.

Medical Certification Form: This form must be completed by a physician or certified health professional. It provides detailed information about your medical condition and how it affects your ability to use public transportation.
Proof of Residency: This document verifies your current address. Acceptable forms include a utility bill, lease agreement, or bank statement that displays your name and address.
Emergency Contact Form: This form collects information about someone who can be contacted in case of an emergency. It includes their name, relationship to you, and phone number.
Transportation Needs Assessment: This assessment evaluates your specific transportation needs. It may ask questions about your mobility limitations and preferred travel times.
Authorization for Release of Information: This document allows METROLift to obtain necessary information from your healthcare provider. It is essential for ensuring that all relevant details are considered in your application.

Gathering these documents can streamline the application process for METROLift services. Having everything ready will help ensure that your eligibility is determined quickly and accurately.

The Metrolift Application form shares similarities with the Social Security Disability Application. Both documents require individuals to provide detailed personal information, including their medical history and functional limitations. Each application seeks to establish eligibility for services based on the applicant's disability, necessitating comprehensive responses to ensure accurate assessments. Additionally, both forms often require verification from a medical professional, highlighting the importance of expert input in determining the applicant's capabilities and needs.

Another document similar to the Metrolift Application is the Americans with Disabilities Act (ADA) Eligibility Application. Like the Metrolift form, the ADA application aims to assess an individual's eligibility for specific accommodations based on their disability. Both forms require applicants to disclose information about their disabilities and how these impact their daily lives. Furthermore, they emphasize the necessity of providing accurate and complete information to facilitate the decision-making process regarding eligibility for services or accommodations.

The Supplemental Nutrition Assistance Program (SNAP) Application also resembles the Metrolift Application. Both forms require applicants to provide personal details, including income and household composition. Each application aims to evaluate the applicant's needs and determine eligibility for assistance. Just as the Metrolift form collects information about mobility and transportation challenges, the SNAP application gathers data on food security and nutritional needs, ensuring that individuals receive the appropriate support based on their circumstances.

Lastly, the Medicaid Application shares commonalities with the Metrolift Application. Both documents require detailed personal and financial information to assess eligibility for essential services. The Medicaid Application, like the Metrolift form, often necessitates documentation from healthcare providers to verify medical conditions. Both processes aim to ensure that individuals receive the necessary support based on their health needs and financial situations, reinforcing the importance of accurate information in determining eligibility for services.

When filling out the METROLift Application form, consider the following guidelines:

Provide accurate and complete information. Incomplete forms may delay your application.
Have a friend, guardian, or caregiver assist you if needed. They can help ensure all questions are answered.
Use clear and legible handwriting. This helps prevent misunderstandings.
Include only the last four digits of your Social Security Number. Do not provide the full number.
Make sure to sign and date the application. An unsigned application will not be processed.

Things to avoid when completing the form:

Do not leave any questions unanswered. Each question is important for determining eligibility.
Avoid providing false or misleading information. This can result in denial of services.
Do not skip the physician's certification on pages 5-6. This step is essential for your application.
Refrain from using medical jargon. Simple language is preferred for clarity.
Do not submit the application without reviewing it for errors. Double-checking can save time.

Understanding the METROLift Application form is crucial for those seeking paratransit services. However, several misconceptions can lead to confusion. Here are ten common misconceptions, along with clarifications to help applicants navigate the process effectively.

Misconception 1: The application can be filled out without assistance.

While individuals can complete the application independently, help from a friend, guardian, or caregiver is encouraged. This support can ensure that all questions are answered accurately and completely.

Misconception 2: Only medical professionals can complete the application.

Although pages 5 and 6 require certification by a physician or certified health professional, the initial sections can be filled out by the applicant or someone assisting them.

Misconception 3: The application is only for those who cannot walk at all.

The application is designed for individuals with various disabilities, including those who may have limited mobility but can still use some forms of transportation.

Misconception 4: All questions must be answered in a specific way.

Applicants should answer questions honestly based on their personal experiences and abilities. There are no "right" or "wrong" answers, just truthful reflections of their situation.

Misconception 5: Submitting the application guarantees approval.

Submitting the application does not guarantee eligibility. Approval is based on the information provided and the assessment of mobility needs.

Misconception 6: The METROLift service is available to everyone.

METROLift is specifically for individuals with disabilities who cannot use the regular bus service. Not everyone qualifies, and eligibility is determined through the application process.

Misconception 7: The application process is quick and straightforward.

The process can take time, as it requires careful completion and may involve additional assessments. Applicants should be prepared for potential delays.

Misconception 8: You can provide incomplete information without consequences.

Incomplete or inaccurate information can lead to delays or denial of service. It is essential to provide thorough and accurate details.

Misconception 9: The application does not need to be updated once submitted.

Applicants must inform METROLift of any changes in their condition, residence, or contact information after submission to ensure continued eligibility.

Misconception 10: The METROLift service is the same as regular bus service.

While METROLift provides transportation, it is a specialized service designed for individuals with disabilities. It operates differently than the regular bus system.

By addressing these misconceptions, applicants can approach the METROLift Application process with a clearer understanding and a better chance of securing the necessary services.

If "no" or "sometimes," please explain.

If "no" or "sometimes," please explain.

4. Can the applicant walk up and down two steps?

Complete all sections of the METROLift Application form, particularly pages 1 to 4, to provide comprehensive information about your abilities and needs.
Seek assistance from a friend, guardian, or family member if needed, as they can help ensure that all questions are answered accurately and thoroughly.
Pages 5 and 6 require certification from a physician or certified health professional who is familiar with your medical condition. This step is essential for your application to be processed.
Be honest and precise when describing your disability and any assistive devices you use. Accurate information is crucial for determining your eligibility for METROLift services.
Understand that providing false information or failing to comply with the application process may lead to denial of services. Your cooperation is vital.
Keep in mind that METROLift services are designed to assist individuals who cannot use the regular bus service. Therefore, clearly explain any challenges you face when using public transportation.