ACCESS GSO Medical Form (Part B)

ACCESS GSO Medical Form

Part B
The Access GSO Application has two different forms- this one, and the ACCESS GSO Eligibility Questionnaire (Part A), and both forms must be completed and received by GTA.

Please email accessgsoeligibility@greensboro-nc.gov or call (336) 373 2166 with any questions.

Section A. Authorization to Release Information

Please complete and sign Section A on this form. When this form is submitted, applicants will receive an email with a Section B PDF attached. Applicants can download or print this Section B PDF and give or send it to the selected professional for completion.
ApplicantSelected Healthcare Professional
Notice: when you submit this form, you will receive an email with a PDF attachment of this authorization to give to your selected healthcare professional to complete.
Applicant's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Applicant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Email Address*
example@example.com
Applicant's Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name Of Professional*

First NameLast Name
Title*
Applicant's Signature: Signature* Date: Date*

Guardian's Signature is required if applicant is not his/her own guardian
Guardian's Signature: Signature
If you'd like to send your selected professional a fillable PDF for their verification, please type only your name and date of birth on the form below. Then download or print this PDF to send or give to your selected professional. Only your selected professional should complete Section B of this form.
- Section B: Professional Verification
  
  Dear Healthcare Professional:
  
  You are being asked to provide information regarding this individual’s disability. The individual is applying for Americans with Disabilities Act (ADA) paratransit eligibility. The law specifies that ADA paratransit eligibility is provided only to those individuals who (1) as a result of their disability, cannot board, ride or disembark from a regular fixed route bus or (2) have a specific impairment-related condition that prevents them from getting to or from a bus stop.
  
  Please note: This is not intended as verification of the applicant’s disability or medical condition but to determine the effect of that disability or medical condition on the individual’s ability to independently use regular, fixed route bus service.
  
  Greensboro’s regular fixed route bus service is accessible to people with disabilities. All fixed route buses operated by Greensboro Transit Agency (GTA) are equipped with lifts for people who use wheelchairs/scooters. All buses also have a “kneeling” feature that lowers the bus closer to the ground to help people who have difficulty climbing stairs. There is priority seating behind the bus driver for people with disabilities and seniors. Stops and major transfer points are announced at each stop.
  
  Please return the completed form to the applicant, or you may fax it to 336-373-2809, Attention: Access GSO Eligibility Department.
  
  General Questions
- 1. In what capacity do you know the applicant?*
- 2. What is the diagnosed disability or medical condition causing the disability that you are treating the applicant for?*
- PhysicalVisualCognitive
- TemporaryPermanent
- How long do you expect it to last?*
- NoSometimesYes
- Please explain why:*
- YesNo
- Manual WheelchairPower WheelchairScooterWalkerCrutchesCaneWhite CaneOther, please specify
- NoYesSometimes
- Effects of Applicant’s Disability or Medical Condition on Community Travel
- 3 blocks6 blocks9 or more blocksLess than 3 blocks
- 15 minutes30 minutesLess than 15 minutes
- YesNoSometimes
- Please elaborate if necessary
- YesNo
- Why not?*
- YesNoSometimes
- Please elaborate if necessary
- YesNo
- Please elaborate if necessary
- YesNoSometimes
- Additional Information
- Is there any other relevant information about the applicant’s disability or medical condition affecting the applicant’s mobility that would be helpful to GTA in determining ADA paratransit eligibility?*
- Healthcare Professional Signature: Signature* Date: Date*
- Please print your name*
  
  First NameLast Name
- Title*
- License number*
- Telephone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Thank you for your help. If you have questions, please contact the Greensboro Transit Agency at (336) 373-2166, or by email at accessgsoeligibility@greensboro-nc.gov.
- Should be Empty:

ACCESS GSO Medical Form

Section A. Authorization to Release Information

Section B: Professional Verification

General Questions

Effects of Applicant’s Disability or Medical Condition on Community Travel

Additional Information