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Contents

The METROLift Application form is a crucial document for individuals seeking paratransit services in Houston, Texas. It plays a significant role in determining eligibility for METROLift, which is designed to assist those who cannot use regular bus services due to disabilities. The application spans several pages, requiring detailed information about the applicant's personal background, mobility challenges, and medical conditions. Pages one through four focus on gathering essential information, such as the applicant's name, address, and contact details, along with questions about their disability and the assistive devices they use. It’s important to answer all questions thoroughly, as incomplete responses may hinder the eligibility assessment. Additionally, pages five and six must be filled out by a qualified physician or healthcare professional who can provide insights into the applicant's mobility limitations. The form also includes an agreement section where applicants acknowledge the accuracy of their information and authorize the release of medical details necessary for the evaluation process. For those needing assistance, a friend or family member can help complete the application, ensuring that all required information is accurately provided. Understanding the form’s structure and requirements is essential for a smooth application process.

Preview - Metrolift Application Form

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? No Yes
TO BE COMPLETED BY APPLICANT
Name of Applicant
Nombre de solicitante
Last/Apellido First/Nombre Middle/Inicial Nombre de solicitante
Address/Street / Dirección/Calle Apartment Number
Numero de Apatamento
City/Ciudad Zip Code/Codigo Postal
Date of Birth/Fecha de Nacimiento Home Phone Number/En Casa Número de Teléfono Other Phone/Otro Teléfono
Apartment Complex Name/Nombre
de Apartamentos
Gate Code/Codigo de Cochera
Mailing Address/Dirección de Envío
If different from home address/Si diferente de domicilio
Zip Code/Codigo PostalState/EstadoCity/Ciudad
Applicant Signature (required)
Firma
X
Date/Fecha
Name of Emergency Contact/Contacto de Emergencia Relationship/Relación Emergency Phone/Numero de Emergencia
METRO 0447-17-(06/22)
Page 1
INDIVIDUAL AND MOBILITY INFORMATION
2. What assistive device(s) do you use when traveling? (Please check all that apply.)
Support Cane
Crutches
Walker
Leg brace(s)
Other (describe)
Manual wheelchair
Powered wheelchair
Power scooter
Portable oxygen
Trained service animal
Communications device
“White cane”
None
What is the nearest street intersection to your home? (Example: Polk & Wayside)
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.
Can you find your way to a bus stop without getting lost? Yes No
If "no," please explain.
How long can you stand and wait for a bus?
15 minutes 10 minutes 5 minutes Less than 5 minutes
All buses have a "destination sign" in front, which shows the route name and number.
3.
4.
5.
Can you read a bus destination sign?
Can you ask the driver where the bus is going?
Can you give or write a note to the driver?
Can you understand the driver's answer?
If "no" to any questions, please explain.
6.
7.
Yes No
Yes No
Yes No
Yes No
Page 2
Please state your disability(s).
1.
METRO 0447-17-(06/22)
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? Yes No
.
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.
8.
9.
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.)
10.
Have you ever received " orientation and mobility training "or " travel training?" Yes No
If " yes," please list any METRO bus routes on which you can travel:
11.
How do you currently travel (self, family, friends, bus, rail, METROLift, etc.)?
Please explain.
12.
Please tell us the reasons you feel you cannot use METRO’s local fixed-route bus
service for some or all trips.
13.
Do you require someone to travel with you? Yes No
If "yes," please explain
14.
Can you wait independently alone at your residence and places to which you travel?
Yes No
If "no," please explain.
15.
Page 3
If “no” please explain
METRO 0447-17-(06/22)
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: ____________________
Page 4
METRO 0447-17-(06/22)
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:
Excellent Good Fair Poor None Don’t Know
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
3.
In your opinion, can the applicant travel independently from his/her house to the sidewalk?
Yes No Sometimes
If "no" or "sometimes," please explain.
4. Can the applicant walk up and down two steps? Yes No Sometimes
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
Page 3
Page 3
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.
9.
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 No 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
Medical/Social Worker’s License Number
Physician’s/Health Professional’s Signature
State
Telephone #
Zip Code
Fax #
Date
***Note: Additional signature of physician/healthcare professional on his/her
letterhead or prescription verifying completion of application is required.
Page 6
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Document Specifics

Fact Name Description Governing Law
Application Requirement The METROLift application requires detailed personal and medical information to assess eligibility for paratransit services. Americans with Disabilities Act of 1990, 49 CFR 37.121
Completion Assistance Applicants may receive help from friends, family, or caregivers to complete the application. None
Physician Certification Pages 5-6 must be completed and certified by a physician or certified health professional familiar with the applicant's condition. None
False Information Consequences Providing false or misleading information can result in denial of METROLift services. Americans with Disabilities Act of 1990, 49 CFR 37.121

Metrolift Application: Usage Instruction

Filling out the METROLift Application form requires careful attention to detail. This form is essential for determining eligibility for METROLift services, which assist individuals who are unable to use local bus transportation. Ensure that all sections are completed accurately, as incomplete information may delay the processing of your application.

  1. Obtain the METROLift Application form from the designated source.
  2. Fill in your personal information on the first page, including your name, social security number (last four digits only), address, date of birth, and contact numbers.
  3. Provide the name and phone number of an emergency contact.
  4. Complete the Individual and Mobility Information section, answering questions about your disabilities and assistive devices used for travel.
  5. Indicate your ability to walk to the nearest intersection and navigate to a bus stop without assistance.
  6. Answer questions regarding your ability to read bus destination signs and pay fares on the bus.
  7. Detail how you currently travel and whether you require assistance while traveling.
  8. Sign and date the application at the bottom of the page.
  9. If someone else is completing the form on your behalf, provide their name, relationship, and signature in the designated area.
  10. Pages 5 and 6 must be completed and certified by a physician or certified health professional. Ensure they have all necessary information to fill out their section accurately.

Learn More on Metrolift Application

What is the purpose of the METROLift Application form?

The METROLift Application form is used to determine eligibility for METROLift service. This service is designed for individuals with disabilities who cannot use the regular METRO bus service. The application gathers important information about your mobility and medical condition.

Who can help me fill out the application?

A friend, guardian, caregiver, agency service representative, or family member can assist you in completing the application. It’s important to have accurate information to ensure your eligibility is properly assessed.

What information is required on pages 1-4 of the application?

Pages 1-4 require personal information such as your name, address, date of birth, and social security number (last four digits only). You will also need to provide details about your disability, assistive devices, and your ability to use METRO bus services.

Why do I need a physician to complete pages 5-6?

Pages 5-6 must be completed and certified by a physician or certified health professional who understands your condition. This helps METRO accurately assess your needs and determine your eligibility for METROLift services.

What if I have questions while filling out the application?

If you have questions, you can call METROLift Customer Service at 713-225-0119. They can provide guidance and clarify any uncertainties you may have about the application process.

What happens if I provide false information on the application?

Providing false or misleading information can lead to denial of METROLift services. It’s essential to be truthful and accurate in your responses to avoid any issues with your application.

Can I use METROLift if I can use the regular bus service sometimes?

Yes, you can apply for METROLift even if you can use the regular bus service on occasion. However, you will need to explain your specific circumstances and why you require METROLift for certain trips.

What should I do if my condition changes after I am approved for METROLift?

If your condition changes, you must promptly inform METROLift. This includes changes in your mobility, residence, or contact information. Keeping METROLift updated ensures that your service continues to meet your needs.

How do I know if my application has been processed?

You will receive a notification once your application has been processed. If you have concerns about the status of your application, feel free to reach out to METROLift Customer Service for updates.

What is the next step after submitting my application?

After submitting your application, it will be reviewed by METRO staff. If additional information is needed, they may contact you or your physician. Once your eligibility is determined, you will be notified of the outcome.

Common mistakes

Filling out the METROLift Application form can be a straightforward process, but there are common mistakes that applicants often make. Being aware of these can help ensure a smoother application experience and avoid delays in receiving services.

One frequent mistake is not answering all questions completely. Each question is designed to gather important information about the applicant's ability to use METRO bus services. Leaving questions blank can lead to confusion and may result in an incomplete application. Always take the time to provide thorough responses to each item.

Another common error is failing to provide accurate information about medical impairments or functional capacity. The application requires precise details to assess eligibility. Misrepresenting or overlooking important aspects of one’s condition can hinder the approval process. It's essential to be honest and clear about any disabilities or limitations.

Some applicants neglect to include their emergency contact information. This information is crucial for METROLift in case they need to reach someone in an emergency. Make sure to provide a reliable contact person and their phone number.

Additionally, many people do not have their physician or certified health professional complete the necessary sections on pages 5 and 6. These pages are critical for verifying the applicant’s condition. Without a completed certification, the application may not be processed. It is advisable to schedule an appointment with a healthcare provider to ensure this part is filled out correctly.

Another mistake is not signing the application. The applicant's signature is a required element that confirms the information is accurate. Omitting this can lead to automatic rejection of the application. Always double-check that the signature is included before submitting the form.

Some individuals provide outdated or incorrect contact information. If there are changes in residence or phone numbers, these should be updated on the application. Providing current information ensures that METROLift can reach the applicant when necessary.

Another common issue is not explaining "no" answers adequately. If the applicant answers "no" to questions about their ability to walk or navigate to a bus stop, it’s important to provide a clear explanation. This additional context helps METROLift understand the applicant’s situation better.

Many applicants also forget to specify the assistive devices they use. This information is vital for determining the best services to accommodate the applicant’s needs. Be sure to check all applicable boxes and describe any additional devices that may not be listed.

Finally, some individuals may not seek help from friends or family when needed. The application allows for assistance from caregivers or family members, which can be beneficial in ensuring all information is filled out accurately. Don’t hesitate to ask for help if needed; it can make the process much smoother.

By avoiding these common mistakes, applicants can enhance their chances of a successful application for METROLift services. Careful attention to detail and thoroughness are key in this process.

Documents used along the form

When applying for METROLift services, several additional documents may be required to ensure a comprehensive assessment of eligibility. These documents help provide a clearer picture of the applicant’s needs and capabilities. Below is a list of commonly used forms and documents that accompany the METROLift Application form.

  • Medical Certification Form: This document must be filled out by a physician or certified health professional. It provides detailed information about the applicant's medical condition and functional abilities, which is crucial for determining eligibility for METROLift services.
  • Personal Mobility Assessment: This assessment evaluates the applicant's ability to navigate their environment. It includes questions about the use of assistive devices and the ability to travel independently, which helps METROLift staff understand the applicant's specific mobility challenges.
  • Emergency Contact Form: This form collects information about a designated emergency contact person. It is essential for ensuring that someone can be reached in case of an emergency while the applicant is using METROLift services.
  • Proof of Residency: Applicants may need to provide documentation that verifies their home address. This can include utility bills or lease agreements, which help confirm that the applicant resides within the service area.
  • Authorization for Release of Information: This document allows METROLift to obtain necessary medical and personal information from healthcare providers. It ensures that the applicant's privacy is respected while facilitating the eligibility determination process.

Each of these documents plays a vital role in the application process for METROLift services. By providing accurate and complete information, applicants can help ensure that their needs are understood and met, paving the way for a smoother experience with public transportation.

Similar forms

The Metrolift Application form shares similarities with the Social Security Administration (SSA) Disability Application. Both documents require individuals to provide detailed personal information, including their medical conditions and functional capabilities. The SSA application assesses an individual's eligibility for disability benefits, while the Metrolift form determines eligibility for paratransit services. In both cases, accurate and complete information is essential for the review process, and applicants may receive assistance from family members or caregivers to ensure thoroughness.

Another document comparable to the Metrolift Application is the Americans with Disabilities Act (ADA) Paratransit Eligibility Application. This application is designed for individuals seeking transportation services under the ADA, similar to how the Metrolift form serves those needing METRO services. Both documents require applicants to describe their disabilities and the specific reasons they cannot use standard public transportation. The emphasis on medical verification from a healthcare professional is a common requirement, ensuring that the information provided is accurate and reliable.

The Medicaid Application also bears resemblance to the Metrolift Application. Both forms necessitate personal and financial information to determine eligibility for services. While the Medicaid Application focuses on healthcare coverage, the Metrolift Application centers on transportation services for individuals with disabilities. Each application requires thorough documentation and may involve a review process that assesses the applicant's needs and circumstances. The compassionate approach to gathering sensitive information is crucial in both instances, as applicants may be vulnerable and in need of support.

Additionally, the Veterans Affairs (VA) Disability Compensation Application shares similarities with the Metrolift Application. Both documents require individuals to disclose their disabilities and how these impairments affect their daily lives. The VA application seeks to provide compensation for service-related disabilities, while the Metrolift application aims to facilitate accessible transportation. Both processes emphasize the importance of accurate information and may involve assessments by qualified professionals to verify claims and determine eligibility.

Lastly, the Supplemental Nutrition Assistance Program (SNAP) Application can be likened to the Metrolift Application. Both forms require applicants to provide personal information and details about their circumstances to assess eligibility for assistance programs. While SNAP focuses on food security, the Metrolift Application addresses transportation needs. In both cases, applicants may need to supply supporting documents and may receive help from others to complete the application accurately, ensuring that all necessary information is conveyed clearly and comprehensively.

Dos and Don'ts

When filling out the METROLift Application form, it is essential to approach the task with care and attention. Here are some important dos and don'ts to keep in mind:

  • Do answer all questions completely and accurately. This information is crucial for determining eligibility.
  • Do seek assistance from a friend, family member, or caregiver if needed. They can help ensure that the application is filled out correctly.
  • Do provide detailed explanations for any "no" answers. This will help clarify your situation and needs.
  • Do include your physician's information on pages 5-6. Their certification is necessary for your application.
  • Don't leave any sections blank. Incomplete applications may delay the processing of your request.
  • Don't provide false information. Misleading details can result in denial of services and may have legal consequences.

By adhering to these guidelines, you can help ensure that your application is processed smoothly and efficiently. Your honesty and thoroughness are key to receiving the assistance you need.

Misconceptions

When it comes to the METROLift application form, there are several misconceptions that can lead to confusion for potential applicants. Understanding these misconceptions can help ensure a smoother application process. Here are five common myths:

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

    • Many believe they must complete the application on their own. However, a friend, family member, or caregiver can assist in filling out the form. This support can be invaluable in ensuring that all information is accurately represented.

  • Misconception 2: Only medical professionals can fill out the entire application.

    • While pages 5 and 6 require certification from a physician or certified health professional, the initial sections can be completed by the applicant or someone assisting them. This collaborative approach can help clarify the applicant's needs and circumstances.

  • Misconception 3: Providing incomplete information won’t affect eligibility.

    • Some individuals think that minor omissions won’t impact their application. In reality, METROLift requires comprehensive and accurate information to determine eligibility. Incomplete answers can delay the process or even lead to denial of services.

  • Misconception 4: Past applications do not need to be disclosed.

    • Applicants may assume that previous applications are irrelevant. However, disclosing whether you have applied for METROLift before is essential, as it helps the review process and can provide context for your current application.

  • Misconception 5: The application process is only for those who cannot use public transportation at all.

    • Some people think they must be completely unable to use any form of public transport to qualify. METROLift is designed for individuals who may be able to use some services but require additional support due to their specific disabilities. Understanding this can open up options for many potential users.

By addressing these misconceptions, applicants can approach the METROLift application process with greater confidence and clarity, ensuring that their needs are accurately represented and understood.

Key takeaways

Key Takeaways for Filling Out the METROLift Application Form

  • Complete all sections of pages 1 to 4. This includes personal information and details about your ability to use METRO services.
  • Seek assistance if needed. A friend, family member, or caregiver can help you fill out the application.
  • Pages 5 and 6 must be filled out and signed by a physician or certified health professional familiar with your condition.
  • Provide accurate information regarding your medical impairment and functional capacity. This is crucial for determining your eligibility.
  • Contact METROLift Customer Service at 713-225-0119 if you have questions about the application process.
  • Be honest in your responses. Providing false information can lead to denial of services or termination of eligibility.