You Thrive Paratransit

You Thrive Paratransit Client Application Form

Please allow one (1) business day for application processing before scheduling an appointment

APPLICATION FOR TRANSPORTATION DISADVANTAGED SHARED RIDE PARATRANSIT SERVICES

The State of Florida Commission for the Transportation Disadvantaged mandates that an application must be on file for every rider, even if the individual resides in a nursing home. Since the Commission operates through state government funding, anyone who has a trip must have a completed and signed application on file, either by client or guardian, indicating that they meet the definition of “Transportation Disadvantaged”.

This application form must be completed prior to receiving transportation services through the State Transportation Disadvantaged services.

Information contained in this application is private, confidential, and protected under the "Right to Privacy Act" and “HIPAA” and will not be shared. Trans Hernando does not accept any insurance as a form of payment.

If you need further information or assistance in completing this application, please contact our office at 352-799-1510 or email us at transit1@mfcs.us.com

Instructions for completing this application:

>When completing the application, please type or print legibly and sign where indicated.

> Illegible, incomplete, or unsigned applications will not be accepted and will be returned.

> In order to qualify for a reduced fare, you must provide proof of household income, employment, or veteran status. Otherwise your fare will remain $5.00 each way.

> Application must include a copy of either your drivers license or government issued photo ID.

> Processing of this application takes 1 business day and begins after a completed application is received.

>All applicants must call the office for application status.

>Completing this application does not automatically certify the applicant for services

>Please read the following rider guidelines carefully and acknowledge you have read and understand them.

Rider Guidelines

>Due to availability of program funds, trips may be denied based on trip purpose. Medical appointments and life sustaining trip are the highest priority.

>Origin and destination locations must be within Hernando County.

>Applications will remain active for 730 calendar days (two years). After such time, applicants must reapply to continue services.

>Proof of Household Income is required (SSI, SSDI, Pension, Bank Statement etc.) to apply for a reduced fare. Regular Fare is $5.00 each way. The special fare for our veterans is $1.00 each way, with proof of service (DD214, Veteran’s ID, etc.). If you’re recertifying, you must provide updated proof of income to continue to qualify for a reduced fare. We do not need proof of veterans status for recertification.

>Reservations can only be made up to 2 weeks in advance and no later than 12:00 pm the business day before the appointment.

>Our office hours are 7:30 am—4:00 pm. Reservations may be canceled after hours via voicemail without penalty, however; reservations will not be taken after hours.

>Cancellations should be made at least 1 hour before your scheduled pick-up time. If a cancellation is not received in that time it is considered a no show. When more than 3 no shows in a 60 day period occur, the rider will be suspended from transport for 30 days.

>We operate in a 2 hour window. Passengers may be picked up as early as 2 hours before their appointment and must be ready to go at any time within that time frame. Passengers will call when they are ready to return home, and the driver has up to 2 hours to pick them up. If passenger is not ready to leave when the driver arrives, it is considered a no show.

>The first guaranteed appointment time is 8:00 am. The final pick up time is no later than 3:00 pm and in some areas 2:00 pm. Any rider later than that will NOT have a return home. Their ride will be canceled, and they will receive a no show.

>Driver can only wait 3 minutes for passengers after arriving for their pick up.

>Driver cannot assist mobility devices into or out of a residence, up and down stairs, through grass, sand or mud.

>All scheduled escorts may ride free of charge, however; the escort is responsible for bringing passenger to the vehicle and taking them to the appointment from the vehicle.

>Drivers will only be able to provide passengers with "stabilizing" assistance. They cannot provide weighted support.

>Drivers cannot assist clients to treatment sites inside buildings or from one test site to another.

>Wheelchairs must have foot rests, brakes, be able to be tied down in the vehicle and weigh under 600lbs including passenger. We do not take transport chairs. All motorized wheelchairs must be checked by management before it can be transported.

>Shopping will only occur on designated days, and to stores closest to passenger’s home or on drivers route. Shoppers may only bring up to 3 bags on the vehicle. Wheeled, foldable shopping carts are permitted.

>No food or drinks are allowed on the vehicle unless medically necessary.

Any guidelines are subject to change without notice and are based on funding and driver availability.

I have read and understand the rider guidelines

Will this service be used for dialysis or chemotherapy treatments? *

Yes

First Name *

Last Name *

Date of Birth * +

Social Security Number *

Street Address *

Unit

Address Line 2

Name of Apartment Complex, Subdivision, or Mobile Home Park

Gate Code

City *

State *

Zip Code *

Primary Phone Number *

Secondary Phone Number

Email Address

	Name	Phone Number
Emergency Contact	Name	Phone Number

Other Household Members

	Will this member also use the service?	Name	Date of Birth	Social Security Number
Member 1	Will this member also use the service?	Name	Date of Birth	Social Security Number
Member 2	Will this member also use the service?	Name	Date of Birth	Social Security Number
Member 3	Will this member also use the service?	Name	Date of Birth	Social Security Number
Member 4	Will this member also use the service?	Name	Date of Birth	Social Security Number

Please answer: *

	Check Yes or No
	Yes	No
I am 60 years or older.	Yes	No
My income falls below current federal poverty guidelines	Yes	No
I am disabled	Yes	No
I am a veteran	Yes	No
I am able to travel alone	Yes	No
My driveway/ entrance is accessible with my mobility aid	Yes	No
I am able to transfer from a wheelchair to a car	Yes	No
I am able to climb three 12 inch steps to board a vehicle that has handrails	Yes	No

Will this transportation be used for employment? (If so, you must provide proof of employment - i.e. paystub.) *

Yes

Do you require an escort (over 17) to accompany you? (It is the passenger's responsibility to advise the office that an escort is needed prior to scheduling a trip. It is the escort's responsibility to assist the passenger to and from the vehicle and the appointment ) *

Yes

Do you use Mobility assistance? (All wheelchairs must have working brakes and the footrests attached.) *

Yes

What types of mobility aids do you or your household members use? *

	Wheelchair	Cane	Walker	Powered Wheelchair	Service Animal	Portable Oxygen	None
You	Wheelchair	Cane	Walker	Powered Wheelchair	Service Animal	Portable Oxygen	None
Member 1	Wheelchair	Cane	Walker	Powered Wheelchair	Service Animal	Portable Oxygen	None
Member 2	Wheelchair	Cane	Walker	Powered Wheelchair	Service Animal	Portable Oxygen	None
Member 3	Wheelchair	Cane	Walker	Powered Wheelchair	Service Animal	Portable Oxygen	None
Member 4	Wheelchair	Cane	Walker	Powered Wheelchair	Service Animal	Portable Oxygen	None

If you are using oxygen, the tank must be portable and able to be carried by client and/or attached to wheelchair.

Oxygen tanks on a wheeled carrier are not permitted. Client must provide sufficient oxygen for trip possibly lasting several hours.

Notes or Special needs:

Monthly Income

Please include your total gross annual household income below. In order to process your request for a reduced fare, you must provide proof of household income with your application. If no proof of household income, veterans status or employment is received, your fare will remain $5.00 each way.

	Amount
Salary	Amount
SSI	Amount
SSDI	Amount
Pension	Amount
Interest/Dividends	Amount
Workman's Comp	Amount
Other	Amount

Acceptable forms of proof of income. Provide proof of all that your household receives:

Social Security Income Verification
Retirement/ Pension Statement
Current Bank Statement
Unemployment Compensation Verification
First page of your Tax Return
Current Pay Check Stubs (minimum of 2)

Attachments (proof of income, proof of employment, proof of veterans status, identification etc. )

I understand that the information obtained in the certification process will only be used to determine eligibility for paratransit services. Information contained in this application is private, confidential, and protected under the “Right to Privacy Act” and will not be shared or utilized for any other purpose. The provision of your social security number is mandatory and your information will remain confidential and protected under penalty of law. We will not use or distribute your social security number for any reason, including referrals to other agencies. I certify that all of the above information is true to the best of my knowledge.

Signature of Applicant or Representative *

clear

Date * +

How did you hear about our service?

Please allow one (1) business day for application processing before scheduling an appointment