[City of El Paso] LIFT Application Verification

LIFT Application for Paratransit Transportation Verification

Please have your Doctor or a certified Sun Metro LIFT representative complete and sign this form.

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Applicant's Full Name

Applicant's Date of Birth (MM/DD/YYYY)

Dear Doctor/LIFT Representative:

Sun Metro LIFT provides door-to-door transportation service on a share-ride basis using small buses equipped with hydraulic wheelchair lifts. This service is available to persons who because of their disability, are prevented from:

Independently getting to/from a bus stop or transfer point using traditional Sun Metro fixed-route buses
Independently boarding, riding and exiting a Sun Metro fixed-route bus
Boarding or getting to/from a bus stop because of the inability of the bus to deploy the lift or ramp at an inaccessible bus stop

The above applicant is applying for Sun Metro LIFT services and is kindly requesting information regarding their disability. This information will allow Sun Metro LIFT to properly evaluate the applicant’s inability to ride Sun Metro’s traditional fixed-route system and thereby becoming eligible for Sun Metro’s paratransit system.

Thank you for your cooperation.

Please print and refrain from using medical codes.

Capacity in which you know the applicant:

Condition causing the disability:

Is the condition temporary?

Yes

If yes, what is the expected duration?

If the applicant has a disability affecting mobility, is the applicant able to travel without assistance?

Yes

Sometimes

If you indicated ‘no’ or ‘sometimes’, please explain:

Is the applicant able to travel up to ¼ of a mile without assistance or equivalent to 4 blocks?

Yes

Is the applicant able to wait outside for 10 minutes without assistance or support?

Yes

If you checked Other, please explain:

Does the applicant have a visual impairment? (e.g. Peripheral vision, Macular Degeneration, Cataracts etc.)

Yes

If yes, please complete the applicant’s visual acuity:

Right eye:

Left eye:

Both eyes:

If other vision condition, please describe:

If the applicant has a visual impairment, is the applicant able to travel after dark independently?

Yes

Sometimes

If you indicated ‘no’ or ‘sometimes’, please explain:

Does the applicant have a hearing impairment?

Yes

If yes, please explain condition:

Does the applicant have a cognitive impairment?

Yes

If you indicated ‘yes’, please explain condition:

If the applicant has a cognitive impairment, can the applicant provide general information upon request? (i.e., telephone number, address, name)

Yes

Sometimes

If you indicated ‘no’ or ‘sometimes’, please explain:

Can the applicant deal with unexpected situations in daily routine?

Yes

Sometimes

If you indicated ‘no’ or ‘sometimes’, please explain:

Can the applicant ask for, understand and follow directions?

Yes

Sometimes

If you indicated ‘no’ or ‘sometimes’, please explain:

Can the applicant safely and effectively travel in a crowded area?

Yes

Sometimes

If you indicated ‘no’ or ‘sometimes’, please explain:

Does the applicant take any medications?

Yes

If yes, does the medication cause any side effects that would impact the applicant’s functional ability?

Yes

Sometimes

If you indicated ‘yes’ or ‘sometimes’, please explain:

Are there any other conditions or disabilities that would prevent this applicant from riding the traditional wheelchair-accessible fixed route that Sun Metro should be aware of?

Should we have further questions regarding the applicant most limiting functional ability, do you authorize Sun Metro LIFT reach out to you for further questions?

Yes

Important: Sun Metro LIFT will only use this information to determine the applicant’s eligibility to use Sun Metro LIFT. Sun Metro LIFT will keep this information confidential and secure and will only use it for transportation-related purposes.

Phone Number

Applicant's Doctor or LIFT Representative's Signature

First Name

Last Name

Choose how to sign

Draw Type

I certify that the information provided is true and correct to the best of my knowledge.