Application for Transit Plus Service
Client Information
Client Last Name
*
Client First Name
*
Client Middle Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Other
SSN
*
I do not have an SSN
Are you already a Transit Plus Client
Please Select
Yes
No
Client ID
Mobile Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Address:
*
Apt/Unit:
City:
*
State:
*
Zip:
*
Should the Transit Plus Office use this mailing address for all future correspondence?
*
Yes
No
Mailing Name
Mailing Address:
*
Apt/Unit:
City:
*
State:
*
Zip:
*
Emergency Contact Information
Emergency Contact Name (Last, First, M.I.)
*
Relationship to Client
*
Address:
Apt/Unit:
City:
State:
Zip:
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Which of the following best describes the current living arrangement of the applicant?
*
Private Home/ Apartment
Senior Apartment
Rehab/Skilled Nursing Facility
Assisted Living Facility
Group Home
Long-term Care Program Affiliation
Is the applicant currently enrolled in a Wisconsin Department of Health Services care Program? (Mark all that apply)
*
My Choice Family Care-Care Wisconsin
Community Care
iCare
PACE (Program of All-inclusive Care for the Elderly)
IRIS: (Premier, iLife, Outreach Health, GT Independence, Adovocates4U, Connections, First Person Care Consultants, TMG)
Title 19/ Medicaid
Not currently enrolled in a care program.
Other
If Other, please indicate the name of the program
Please include the following contact information for any affiliated care program case manager, representative or consultant:
Case Manager/Consultant Name (Last, First, M.I.)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Assistive Devices Inventory
Please mark all the assistive devices that the applicant uses all or some of the time:
*
White Cane
Walking Cane
Crutches
Walker/Rollator
Prosthesis
Portable Oxygen
Service Animal
Manual Wheelchair
Motorized Wheelchair
Extra Wide Wheelchair (> 30 "wide)
Motorized Scooter
None
Other
If Other, please describe the assistive device below
* Please note, individuals using mobility devices that exceed 30” in width and/or 48” in length (measured 2” above the ground) or applicants and their mobility devices having a combined weight of more than 600lbs when occupied, may not be able to be accommodated on Transit Plus vehicles.
Authorization to Disclose Protected Health Information
I certify that, to the best of my knowledge, the information given on this application is true and accurate. I understand that MCTS will rely upon this information when determining my eligibility for participation in the Transit Plus program. I also understand that providing false or misleading information could result in my eligibility status being revoked or denied. I authorize the provider(s) named here, his/her officers, employees, agents, contractors, members, directors, shareholders or affiliates entrusted with handling medical records, to disclose to MCTS/Transit Plus all of the protected health information relating to me that is reasonably necessary for the provider to fully and accurately complete the Healthcare Provider Verification portion of this application.
Name of Health Care Provider
*
Office or Facility Address
Provider Office Phone
*
Please enter a valid phone number.
Email
example@example.com
Authorization Statement
This authorization shall remain in effect until my eligibility for Transit Plus paratransit services is finally determined or 90 days from the date of the authorization, whichever occurs first. I acknowledge that I have the right to revoke this authorization at any time by sending written notification to the persons named above. I understand that the revocation of this authorization is not effective to the extent that the named provider has relied upon it for the use or disclosure of the protected health information prior to receiving my written revocation notice.I understand that any protected health information disclosed pursuant to this Authorization to an individual or entity that is not covered by state and federal privacy laws and regulations may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.I acknowledge that the named persons will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I sign this Authorization.
Applicant's Name
*
Applicant Signature
*
Check here to use my typed name as my certified signature.
Date
*
-
Month
-
Day
Year
Date
The following Representative signed on my behalf:
*
As the Applicant, I signed on my own behalf.
Power of Attorney
Legal Guardian
Parent (if applicant is a minor)
Submit
Should be Empty: