Multiple Agencies 10/25/2017 - Laserfiche WebLink

Regional Reduced Fare Permit — Certification of Eligibility kiApplicant's Release— Please Print I hereby authorize the physician to release any information necessary to complete this certification.I understand that this information is confidential and shall not be released without my approval or a court order.I understand that the transit agency issuing this permit shall have the right and opportunity to verify my eligibility for a Regional Reduced Fare Permit. I understand that if any of the statements made on this application form are false or inaccurate,I will lose the privileges granted by the Regional Reduced Fare Permit and be subject to criminal prosecution in accordance with Washington State 111qCLaw for fraud(RCW#9A.56.020). Co Name First Middle Last Address City State ZIP Date of Birth Phone No. Applicant's Signature Date Washington State Licensed:•Physician (M.D.)•Psychiatrist•Psychologist(Ph.D.)•Physician's Assistant(P.A.) •Advanced Registered Nurse Practitioner(A.R.N.P.)•Audiologist certified by the American Speech-Language-Hearing Association •Osteopathic Physician(D.O.)—Signatures of Health Care Providers other than these are not acceptable. 1. This applicant must meet at least one of the criteria and conditions listed in the Medical Eligibility Criteria and Conditions brochure. 2. The specific Medical Eligibility Criteria number must be noted in the space provided. 3. If section 6.4 is used,this person must be diagnosed by you as being"Acute-at-risky The appropriate subsection(a,b,c,or d) must be included along with the name and phone number of the work activity center,training,or rehabilitation program in which this patient is currently a patient.Note:An applicant's enrollment in a drug or alcohol rehabilitation program does not,in and of itself,meet eligibility requirements. 4. An applicant's financial situation has no bearing on eligibility. r;3 I certify that meets the Medical Eligibility Criteria Section,Subsection If section 6.4(a,b,c,or d)enter name of qualifying program: Please check the appropriate boxes: 0 Yes El No The disability is temporary.Specify length of disability: years months. A temporary disability must be expected to last no longer than 5 years. ❑Yes ❑No The disability is permanent. ❑Yes ❑No This applicant requires a Personal Care Attendant. If yes: ElTemporary ❑Permanent Verification of Approved Health Care Provider—Please Print] Name Phone No. Provider or Agency Address Washington State License No. 1 understand that if any of the statements made on this application form are false or inaccurate,I will be subject to criminal i; prosecution if accordance with Washington State Law for fraud(RCW#9A.56.020). r.. �.t , Signature Date wY Original Signature Only—No Photocopies or FAX Accepted ,, Title VI Notice:All participating agencies in the RRFP program fully comply with Title VI of the Civil Rights Act of 1964 and related statutes and regulations in all programs and activities.For more information,or to obtain a Title VI Complaint Form,please contact the appropriate agency. October2017