Application for NCTD LIFT Paratransit Service

North County Transit District Application Guide for LIFT Paratransit

Thank you for inquiring about eligibility for North County Transit District’s (NCTD) LIFT Paratransit Service. NCTD provides multiple public transportation services for people with disabilities. Eligibility for these services is based on how the disability affects your functional ability to use NCTD’s fixed-route bus and rail service. All NCTD buses and trains are accessible for people with disabilities and include features such as low floors, level boarding, lifts/ramps, audio announcements, designated priority seating areas for people with disabilities, enhanced signage, kneeling buses, and hand rails.

NCTD provides a Reduced Fare Program for eligible seniors, people with disabilities and those on Medicare (S/D/M Program). This program provides discounted fares on NCTD’s fixed-route buses and rail service and is the primary program used by most customers with disabilities in the North County region. Eligible customers can travel on accessible buses and trains at a reduced fare on daily, monthly and 30-day passes. This program is available for people with disabilities who are functionally able to use the fixed-route bus and rail systems as their primary travel option. For more information on the S/D/M Program or to obtain an application, please visit:

· www.GoNCTD.com/reduced-fare-eligibility

· NCTD Customer Service at (760) 966-6500.

NCTD also provides LIFT Paratransit Service. If you are functionally unable to use the fixed-route bus and rail service, you may be eligible for LIFT. LIFT is a shared-ride paratransit service that is available to qualified applicants whose physical or cognitive limitations prevent them from utilizing NCTD’s regular fixed-route bus and rail service. You may request LIFT trips during the same hours of the day and days of the week within a ¾-mile zone of BREEZE fixed-route bus and SPRINTER rail service. LIFT travel time is comparable to the level of service and ride time provided on NCTD’s fixed-route bus and rail service.

Under 49 CFR §37.121 NCTD is mandated to provide paratransit to individuals with disabilities that is comparable to the level of service provided to individuals without disabilities who use the fixed-route bus or rail system. LIFT ELIGIBILITY IS NOT BASED ON AGE, MEDICAL DIAGNOSIS, A REVOKED DRIVERS LICENSE, FINANCIAL STATUS, OR BEING A U.S. MILITARY VETERAN. To be eligible for LIFT, you must have a disability (i.e., physical, mental and/or visual) that prevents you from using NCTD’s fixed-route bus or rail service. People with disabilities who can independently use NCTD’s fixed-route bus or rail service may not qualify for LIFT service.

NCTD uses an independent third-party contractor, ADARide, to provide eligibility determinations for potential LIFT customers. To qualify for LIFT, you must submit an application for NCTD LIFT Paratransit Service. After receipt and review of an application an in-person functional assessment will be scheduled at the NCTD Escondido Paratransit Assessment Center, located at the Escondido Transit Center in Escondido, CA. If you are unable to get to the in-person assessment with your own transportation, NCTD will provide a ride at no cost. Photo identification will be needed to verify your identity for the in-person assessment. The assessment itself is expected to last approximately one hour; however, you should anticipate the total time for the assessment and travel time to and from the assessment facility to be approximately 2 to 3 hours.

LIFT eligibility may be granted for up to 3 years. Customers desiring to continue LIFT service after the eligibility expiration date must reapply and complete the eligibility process prior to their eligibility expiration date in order to prevent a lapse in LIFT service.

You will be notified by mail regarding your eligibility determination within twenty-one (21) calendar days after your complete application has been submitted, OR after the functional assessment is completed. If a determination is not provided to you within 21 calendar days, you will be granted presumptive eligibility until a final determination has been made. If found to be eligible for LIFT service, you will receive a LIFT identification number and a Rider's Guide describing the LIFT service and booking process in more detail. If you are denied unconditional eligibility, you have the right to appeal. Your eligibility determination letter will have more details regarding the NCTD LIFT Appeals process.

For additional information or assistance, please contact NCTD at (760) 966-6500, or review the NCTD website at www.GoNCTD.com/lift.
Personal Information
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther
Is this a new application or a recertification?*

RecertificationNew
Trapeze Customer Number (if known)
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if mailing address is different from Home Address, please provide below)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email Address
example@example.com
Desired notification format (i.e. audio, electronic file such as pdf, large print, Braille, etc)
Emergency Contact

Please give us the name and phone number of a person we can call in case of emergency or if we are unable to reach you at your regular number:
Name*

First NameLast Name
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Relationship*
Do you have a Compass Card?

YesNo
Please provide your Compass Card number:
Do you have a Medi-Cal number?

YesNo
Please provide your Medi-Cal number to assist NCTD in recovering costs related to your non-emergency medical transportation trips:
Please provide your Managed Care Provider:

Aetna Better Health of CaliforniaBCBS of California Promise Health PlanCommunity Health Group Partnership PlanHealth Net Community Solutions, Inc.Kaiser PermanenteMolina Healthcare of California Partner Plan, IncUnitedHealthcare Community PlanOther
Do you require TDD services?

YesNo
Do you live in an assisted living facility or nursing facility?

YesNo
Do you need a Personal Care Attendant (PCA)?

YesNo
Disability/Health Condition Information

Please describe the disability or health condition which prevents you from using fixed-route bus service:
Disability/Health Condition
Is this a temporary disability or health condition?

Yes, it's temporaryNo, it's permanent
If yes, how long do you expect your disability to prevent you from using fixed-route buses?
Are you currently receiving any treatment?

YesNo
If yes, check which treatment(s) apply to you:

Non-weight Bearing ImmobilizationPhysical TherapyChemotherapyRadiation TherapySurgeryMobility TrainingConvalescenceDialysisPsychotherapyMedicationsRehabilitation ProgramNon-Walking CastWeight Bearing ImmobilizationOther
If you are currently receiving treatment, how long is the treatment expected to last?

0-3 months3-6 months6-9 months9-12 monthsOver a year
Describe any side effects you are currently experiencing from the medication/treatment you are receiving:
Healthcare Provider

(Optional, you may leave this blank)
Primary Provider's Name
Institution/Facility/Agency Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email Address
example@example.com
Specialization
Functional Transit Skills and Abilities
Please read the following statements and check the one that best describes your ability:

I am able to ride the transit system independently.I believe I can ride the transit system if someone taught me how to ride.I can use the transit system for some trips but not others.I have a temporary disability and will only need LIFT until I recover.I am not able to use the transit system by myself.
Which of the following skills can you perform without assistance: (Check all that apply)

Ask for and understand written or spoken instructionsCross the streetCorrectly count moneyRemember the steps necessary to board, ride, and alight the bus or trainWait for a bus or train at a stopStand for 15 minutes if there is no place to sitWalk up and down steps if there is a handrailTransfer from one bus or train to anotherStand on a moving bus or train if there is a handrail
Have you had a recent fall which required medical attention?

YesNo
If yes, what is your fall frequency per week?
If yes, did the fall occur while using mobility aid/device?

YesNo
The following list includes common barriers that prevent people from using the bus or rail system. Do any of these barriers apply to you:

Sensitivity to Cold or HeatLight SensitivityLack of curb cutsHills or slopesAir pollutionUnable to transfer buses/trainsUnable to walk/wheel ¼ mile (3 blocks)Unable to walk/wheel ½ mile (6 blocks)Unable to walk/wheel ¾ mile (9 blocks)RainNight BlindnessLack of sidewalksUneven travel pathBus stop not accessibleGood/Bad daysNone
Do you currently use a mobility device when going places?

YesNo
If yes, check which mobility device(s) you use:

Power/Electric wheelchairManual wheelchairPowered scooterWalkerService animalProsthesisLeg bracesCrutchesPortable oxygen in cartPortable oxygen in bagPicture/Alphabet/Communication boardCaneWhite caneOther
If you use a wheelchair or scooter, what is the width and length (in inches):
Width
Length
If you use a wheelchair or scooter, what is the total weight of your mobility device when you are using it (in pounds):
Total Weight
How long have you been using your mobility device?
Note: All NCTD vehicles are able to accommodate, at a minimum, all occupied wheelchairs weighing up to 600 pounds and measuring 30 inches in width and 48 inches in length. If you and your wheelchair exceed those specifications, NCTD will make every effort to accommodate you if the combined weight (wheelchair and occupant) does not exceed the lift/ramp specifications and lift/ramp capacity of the vehicle, and where doing so is consistent with legitimate safety requirements as provided by the Department of Transportation ADA regulations.
Applicant Certification
I understand the purpose of this application is to determine if there are times when I cannot use North County Transit District fixed-route bus and rail service and may therefore require the LIFT service for my public transportation needs. I certify that, to the best of my knowledge, the information in this application is true and correct. I understand that providing false information may result in denial of service as well as penalty under the law. I agree to undergo an in-person assessment of my mobility abilities and limitations for the purpose of making a determination regarding my eligibility for paratransit service as required. I agree to notify NCTD if my condition changes, if I am using a new mobility device, or if I no longer need to use ADA Paratransit service.

I understand NCTD and/or ADARIDE have the right to review my ADA paratransit eligibility at any time, and where circumstances may warrant, I may become ineligible to receive ADA paratransit services.
Signature*

Clear
Date*

MonthDayYear
The following person assisted me in filling out this application:
Name
Agency (if applicable)
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Authorization to Release Medical Information
By signing this application, I understand I am giving consent for NCTD and ADARIDE to use and disclose my protected health information to transfer information to transportation providers and mobility services. I hereby give my permission to NCTD and ADARIDE to contact my healthcare provider to verify my disability and treatment plan for purposes of determining paratransit eligibility.
Signature*

Clear
Date*

MonthDayYear
Optional Support Files

If you have additional documents or images you would like to submit to support your application, please upload.
Files

Browse Files

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North County Transit District Application Guide for LIFT Paratransit

Personal Information

Contact Information

Emergency Contact

Disability/Health Condition Information

Healthcare Provider

Functional Transit Skills and Abilities

Applicant Certification

Authorization to Release Medical Information

Optional Support Files