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The Metrolift Application form is a crucial document for individuals seeking paratransit services due to disabilities that hinder their use of standard public transportation. This form gathers essential information about the applicant's mobility challenges and their ability to navigate public transit options. Completing the form accurately is vital for determining eligibility, so please take the time to fill it out by clicking the button below.

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The METROLift Application form is a crucial document designed to assess an individual's eligibility for METROLift services, which provide essential transportation for those with disabilities who are unable to utilize standard bus services. It consists of several sections that gather comprehensive information about the applicant's personal details, medical conditions, and mobility capabilities. The first four pages require applicants to provide information about their disability, assistive devices, and ability to navigate to a bus stop independently. This information is vital for determining the level of assistance needed. Additionally, pages five and six must be completed by a qualified physician or health professional who can certify the applicant's condition. This ensures that all medical information is accurate and relevant to the application process. The form also emphasizes the importance of thoroughness, as incomplete or inaccurate information may lead to delays or denial of service. For those who may need assistance in filling out the form, support from family members, caregivers, or representatives is encouraged. Clear instructions and contact information for METROLift Customer Service are provided to address any questions that may arise during the application process.

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

➤ PDF File

Fact Name	Details
Application Purpose	The METROLift Application form is designed to assess an individual's eligibility for METROLift service, which provides transportation for those unable to use standard bus services.
Eligibility Assessment	Accurate and complete information is required on pages 1-4 to determine eligibility. Incomplete applications may delay the process.
Medical Certification	Pages 5-6 must be completed by a physician or certified health professional familiar with the applicant's condition, ensuring a thorough evaluation.
Assistance with Application	Applicants may receive help from friends, family, or caregivers to complete the form, ensuring that all necessary information is provided.
Contact Information	Applicants must provide their home address, phone numbers, and emergency contact details for communication and safety purposes.
Signature Requirement	The applicant's signature is mandatory, indicating that the information provided is accurate and that they understand the terms of service.
Legal Framework	The application process is governed by the Americans with Disabilities Act (ADA) of 1990, ensuring equal transportation access for individuals with disabilities.
Service Conditions	Failure to provide truthful information or to comply with METROLift procedures can result in denial or termination of service.
Travel Independence	Applicants must indicate their ability to travel independently and their need for assistance, which is crucial for determining service suitability.

Filling out the METROLift Application form is an important step in determining eligibility for paratransit services. This form requires detailed information about the applicant's mobility, medical conditions, and ability to use public transportation. It is essential to provide accurate and complete information to ensure a thorough review of the application.

Obtain the application form: You can get the METROLift Application form from the METRO website or by visiting a METROLift Customer Service location.
Complete pages 1-4: Fill out your personal information, including your name, address, date of birth, and contact details. Make sure to include the last four digits of your Social Security number.
Provide emergency contact details: Include the name, relationship, and phone number of someone who can be contacted in case of an emergency.
Describe your disability: Clearly state your disability or disabilities in the space provided. Be specific about any assistive devices you use when traveling.
Answer mobility questions: Respond to the questions regarding your ability to walk, use assistive devices, and navigate to bus stops. This section is crucial for assessing your mobility.
Complete the agreement and authorization: Read the agreement carefully, sign, and date it to confirm that the information you provided is accurate.
Have a physician complete pages 5-6: Schedule an appointment with a physician or certified health professional to fill out and certify the remaining pages of the application. This section requires their assessment of your medical condition and mobility.
Review the application: Before submitting, double-check that all sections are complete and accurate. Ensure that all required signatures are present.
Submit the application: Send your completed application to the address provided on the form: 1900 Main P.O. Box 61429 Houston, TX 77208-1429. You may also drop it off in person at a METROLift Customer Service location.

After submitting the application, the METROLift team will review the information provided. They may contact you for further clarification or to schedule an in-person assessment. It's important to keep your contact information updated and to respond promptly to any requests from METROLift to ensure a smooth process.

What is the purpose of the METROLift Application form?

The METROLift Application form is designed to gather essential information about your ability to use METRO bus services. It helps determine your eligibility for METROLift service, which is a paratransit option for individuals with disabilities. Completing the form accurately is crucial, as it allows METRO to assess your needs and provide appropriate services. If you need assistance, a friend or family member can help you fill out the application.

What information is required on the application?

The application requires personal information such as your name, address, and contact details. Additionally, you must provide details about your disability, any assistive devices you use, and your ability to navigate to a bus stop. Pages 5 and 6 must be completed and certified by a physician or certified health professional familiar with your condition. Accurate information about your medical impairment and functional capacity is essential for the eligibility determination.

Can someone else help me fill out the application?

Yes, you can have a friend, guardian, caregiver, agency service representative, or family member assist you in completing the application. Their help can ensure that all questions are answered thoroughly and accurately, which is important for determining your eligibility for METROLift services.

What should I do if I have questions while filling out the form?

If you have questions while completing the METROLift Application form, you can contact METROLift Customer Service at 713-225-0119. They can provide guidance and clarification on any part of the application process, ensuring you have the support you need to complete it accurately.

What happens after I submit my application?

After you submit your application, METRO will review the information provided to determine your eligibility for METROLift services. If additional information is needed, they may contact you or your healthcare provider for clarification. It is important to ensure that all contact information is accurate so that you can receive timely updates regarding your application status.

Incomplete Personal Information: Many applicants forget to fill in all required personal details, such as their full name, address, and contact numbers. This information is crucial for processing the application.
Missing Signatures: Some individuals neglect to sign the application or the physician's section. A signature is essential for validating the information provided and for authorizing the release of medical details.
Inaccurate Medical Information: Providing incorrect or vague information about disabilities or medical conditions can lead to delays or denials. It’s important to be as precise as possible.
Failure to Explain "No" Answers: When answering questions, if the answer is "no," applicants often forget to provide explanations. These explanations are necessary for understanding the applicant's specific needs.
Not Listing Assistive Devices: Some applicants overlook mentioning all assistive devices they use. This information helps METROLift assess the applicant’s mobility needs accurately.
Neglecting to Update Information: If there are changes in the applicant's condition or contact information, failing to update this information can lead to complications in service delivery.

When applying for METROLift service, several other forms and documents may be required to ensure a comprehensive assessment of eligibility. Each of these documents plays a vital role in providing the necessary information about the applicant’s needs and abilities. Below is a list of commonly used forms that accompany the METROLift Application form.

Proof of Disability Documentation: This document verifies the applicant's disability status, which may include medical records, letters from healthcare providers, or disability identification cards. It helps establish the basis for requesting METROLift services.
Physician's Certification Form: This form is completed by a healthcare professional and provides detailed information about the applicant's medical condition and functional limitations. It is crucial for determining eligibility for METROLift services.
Emergency Contact Form: This document lists individuals who can be contacted in case of an emergency. It ensures that METROLift staff can reach someone familiar with the applicant’s needs if necessary.
Travel Training Assessment: If the applicant has undergone travel training, this assessment outlines their ability to navigate public transportation independently. It provides insight into their travel skills and confidence.
Transportation Needs Assessment: This form gathers information about the applicant’s specific transportation needs, including the frequency of travel and preferred times. It helps METROLift tailor services to meet individual requirements.
Consent for Release of Information: This document allows METROLift to obtain and share relevant medical information with healthcare providers as needed. It ensures that all parties involved have access to necessary information for service provision.

Completing these forms accurately and thoroughly is essential for a smooth application process. By providing comprehensive information, applicants can help ensure that METROLift can effectively meet their transportation needs.

Disability Benefits Application: Similar to the Metrolift Application, this document requires personal information and medical details to determine eligibility for disability benefits. Both forms necessitate accurate information about the applicant's condition and functional capacity.
Medicaid Application: This application also seeks detailed personal and medical information to assess eligibility for Medicaid services. Like the Metrolift form, it requires certification from a healthcare professional regarding the applicant's health status.
Social Security Disability Insurance (SSDI) Application: This document requests information about the applicant's disability and work history. Both forms aim to establish the applicant's ability to perform daily activities and their need for assistance.
Supplemental Nutrition Assistance Program (SNAP) Application: Similar in structure, this application collects personal and financial information to determine eligibility for food assistance. Both require comprehensive details to assess the applicant's situation.
Veteran’s Affairs (VA) Disability Claim: This claim form also requires medical documentation and personal information to evaluate eligibility for benefits. Both documents emphasize the importance of accurate medical assessments.
Housing Assistance Application: This application gathers personal and financial information to determine eligibility for housing aid. Both forms require thorough responses to assess the applicant's needs and circumstances.
Public Assistance Application: Like the Metrolift Application, this document collects personal and household information to evaluate eligibility for various forms of public assistance. Both require detailed responses about the applicant's living situation.
Transportation Assistance Application: This form seeks information about the applicant's mobility challenges and transportation needs. Similar to the Metrolift Application, it aims to determine the level of assistance required for transportation.
Long-Term Care Application: This application assesses the need for long-term care services, requiring medical and personal information to evaluate eligibility. Both documents emphasize the necessity of a healthcare professional's input.
Personal Care Assistance Application: This form collects information about the applicant's daily living activities and health conditions. Both applications aim to determine the level of assistance needed to support the applicant's independence.

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

Do read all instructions thoroughly before starting the application.
Do provide accurate and complete information about your medical condition and mobility.
Do ask a trusted friend or family member for assistance if you need help completing the form.
Do ensure that pages 5 and 6 are certified by a qualified healthcare professional.
Don't leave any questions unanswered; incomplete applications may delay the process.
Don't provide false or misleading information, as this can lead to denial of services.
Don't forget to sign and date the application before submitting it.

Here are seven common misconceptions about the METROLift application form, along with explanations to clarify each one:

Only individuals with severe disabilities can apply. Many people think that METROLift is only for those with profound disabilities. However, the service is available for anyone who has difficulty using regular bus services due to various impairments.
The application is too complicated to fill out. While the form requires detailed information, it is designed to be straightforward. Assistance from a friend or family member is encouraged if needed.
You must have a doctor complete the entire form. Only specific pages need to be filled out by a physician or certified health professional. The applicant can complete the majority of the form independently.
Once you apply, you will automatically receive METROLift services. Applying does not guarantee approval. The information provided is used to determine eligibility based on individual needs.
All questions must be answered perfectly. While accurate information is essential, the application allows for explanations where needed. It is more important to be honest about your situation than to provide perfect answers.
You can’t get help from others when filling out the form. In fact, the application encourages applicants to seek help from family, friends, or caregivers to ensure that all necessary information is provided.
Your personal information will not be kept confidential. The METROLift program is committed to protecting your privacy. All personal and medical information is kept confidential and used solely for determining eligibility.

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

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

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

Key Takeaways for Filling Out the METROLift Application Form

Complete all sections of pages 1-4 to ensure eligibility for METROLift service.
Seek assistance from a friend, family member, or caregiver if needed when filling out the application.
Provide accurate information regarding your medical condition and functional abilities.
Pages 5-6 must be certified by a physician or certified health professional familiar with your condition.
Be prepared to explain any "no" responses to questions about your mobility and ability to use public transportation.
Indicate your preferred method of travel and whether you require assistance when traveling.
Sign and date the application to confirm the truthfulness of the information provided.
Notify METROLift of any changes in your condition, contact information, or residence promptly.
Understand that providing false information may result in denial of services.