Healthcare professional verification
For professional use only
Application ID: 1022-2240-0906; Zhao, Chen
HEALTHCARE PROFESSIONAL VERIFICATION
Your client/patient is applying for the Americans with Disabilities Act Paratransit service called ValleyRide ACCESS. The criterion used for determining eligibility is based on one’s functional ability to independently use accessible fixed route buses. There are physical, mental, visual skills required to access public bus so please help document any challenges your client may have in these areas.
Your client/patient must have this form completed by one of the approved healthcare professionals:
1. Medical Doctor / D.O. / Physician Assistant
2. Registered Nurse / Certified Nursing Assistant
3. Occupational Therapist or OTA
3.Physical Therapist or PTA
4.Masters Level Social Worker
5. Psychologist
6.Psychiatrist
7.O&M Specialist
8.Special Education Teachers
9. Rehabilitation Counselors
10. Ophthalmologist
11.Recreation Therapist
12. Chiropractor
Your participation is vital as incomplete applications will be deemed ineligible and your client / patient will not be able to use the ADA paratransit service.
The information shared will be protected per the requirements identified in the Health Insurance Portability and Accountability Act (HIPPA) and your patient/client has agreed to allow Valley Regional Transit and it’s eligibility contractor, Adaride.com to contact you for this information via the application. Your cooperation and assistance is greatly appreciated. If you have any questions or comments please do not hesitate to contact us @
1-877-232-7433
,
www.adaride.com
ADDRESS / FAX / EMAIL
Please forward both COMPLETED forms to:
ADARIDE 19300 S. HAMILTON AVE SUITE #120 GARDENA, CA 90248
or FAX to: (310) 410-0239
or Email to: info@adaride.com
Application ID: 1022-2240-0906; Zhao, Chen
1. Name of patient / Client
Your professional information
First name:
Middle name:
Last name:
Professional license#:
Profession:
E-mail address:
Day phone:
Mobile phone:
Address
Street#:
Street:
Apt#:
City:
State:
Application ID: 1022-2240-0906; Zhao, Chen
2. Please list the diagnosis you are treating your client / patient for and any other diagnosis that your client may have
3. Please indicate which of the following category most limits your client/patient.
You can check more than one category if both disabilities limit your client’s/patient’s independence and mobility.
Mental
Physical
Visual
If you have chosen Physical , please choose categories:
Cardio vascular
Organ failure / transplant / diabetes
Gastrointestinal disorders
Orthopedic conditions
Geriatric disorders
Other
Infectious diseases / immunology
Pediatric disorders
Neurologic disorders
Pulmonary disorders
Oncology and hematology
Application ID: 1022-2240-0906; Zhao, Chen
4. Date of onset or date patient began services
5. Which statement best describes your patient’s condition?
Being treated and hopes to improve
Permanent condition that is not expected to change
Disease is advanced and considered terminal
Condition should not interfere with independent bus usage
None of the above
6. Prognosis______________________________
7. Treatment plan with start date and anticipated completion date______________________________
8. Does the applicant take on medications which affect their ability to travel?
Yes / Sometimes
No / Don't know
9. Have you ever prescribed or are you aware of device your client / patient currently uses?
None
Cane
Power / Electric Wheelchair
Crutches
Manual Wheelchair
Communication Board
Scooter
White Cane
Walker
Leg Braces
Sport Wheelchair
Portable Oxygen
Service Animal
Picture/Alphabet Board
Prosthesis
Segway
Other
Application ID: 1022-2240-0906; Zhao, Chen
10. Are your client's / patient’s symptoms episodic?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
11. Are you aware of any challenges your client / patient has with balance?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
12. Are you aware of any challenges your client / patient has with strength and endurance?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
13. Do you think your patient/client could independently ambulate / wheel 3/4 of mile (with a mobility device and brief rest periods if needed)?
Yes
No
Sometimes
Do not know
If you have chosen No/Sometimes, please elaborate:
14. Are you aware of any challenges your client / patient has with memory?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
15. Are you aware of any challenges your client / patient has with breathing?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
16. Are you aware of any challenges your client / patient has with crossing streets?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
17. Are you aware of any challenges your client / patient has with ambulating on hills?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
18. Do you have any safety concerns for your client / patient in using a bus by themselves (e.g. compromised immune system, panic attacks, cognitive deficits, risk of falling etc)?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
19. Are you aware if weather has an adverse impact on your client's / patient’s abilities?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
20. Are you aware of any visual impairment that may challenge your client / patient in using the public transportation system?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
21. Are you aware of any hearing impairment that may challenge your client / patient in using the public transportation system?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
22. Are you aware of any inappropriate social behavior exhibited by your client / patient?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
23. Is your client / patient capable of expressing their needs?
Yes
No
Sometimes
Do not know
If you have chosen No/Sometimes, please elaborate:
24. Are you aware of any mobility or travel training that your client / patient is planning on or participating in?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
25. Do you have any additional comments that may help document your client's/patient's abilities/challenges in getting to, using, and commuting on a bus?
Yes
No
Sometimes
Do not know
If you have chosen Yes/Sometimes, please elaborate:
26. I understand the purpose of this application is to determine if there are times when the applicant cannot use VRT's city bus service and may require the VRT ValleyRide program for public transportation needs. I certify that, to the best of my knowledge, the information in this form is true and correct. (Sign your name or check box below if completing this online)
Signature
Signature
27. Title__________________________________________________
28. Date__________________________________________________
