MTA's Paratransit Service Eligibility

Paratransit Service Eligibility Application

Please note: You can save your progress and come back later.
The Paratransit Application

Choose, "No" to continue filling the form out online.
Or, if you prefer to download, print and fill the form? Click, "yes"

YesNo
Paratransit Healthcare Verification Form PDF

Are you the Paratransit Applicant or are you filling this form out on behalf of the Applicant?

I am NOT the Applicant.

I am filling out this form on behalf of someone requesting Paratransit Service.
Your Name:*

First NameLast Name
Your Address

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number to Reach You
Please enter a valid phone number.
Your Email Address*
example@example.com

Applicant's Contact Information
Applicant’s Name:

First NameLast Name
Applicant’s Address

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number to reach Applicant*
Please enter a valid phone number.
Applicant’s Email (if available)
example@example.com

Tell us about your Disability.
Explain your disability/health condition:
What is your disability status?

PermanentTemporary
If Temporary, for how long?

Your Emergency Contact

Who do we call for you when there is an emergency?
Emergency Contact’s Name:

First NameLast Name
Their relationship to you:
Their Primary Phone Number*
Please enter a valid phone number.
Another Phone Number
If they have another number where they can be reached.
Emergency Contact’s Address

Street Address

Street Address Line 2

CityState

Zip Code

Healthcare Verification Form

This part of the application MUST be downloaded and filled out by the applicant’s licensed or certified healthcare professional, which may include, but is not limited to a licensed physician or nurse, vocational rehabilitation counselor, or social worker. A signature is required.
STOP & Read this!

Only continue this if you have a COMPLETED Healthcare Verification Form in order to continue. Has your form been completed, signed and it's ready to be uploaded?
Is your COMPLETED form ready?

No.I have NOT COMPLETED the Healthcare Verification Form. I'll save my application progress and upload it later.Yes. I have COMPLETED the Healthcare Verification Form in order to continue.
Upload your completed Healthcare Verification Form here or fax it to (478) 803-2537.

If you have a completed Healthcare Verification Form, you can upload it here or fax it to (478) 803-2537.
Cancelof
I certify that all of the information I have provided in this application is true and accurate.

I understand that falsifying my application will result in the denial of services.

I understand that all information will be kept confidential, and only the information required to provide the services will be disclosed to those who perform the service(s).

I understand that Macon-Bibb County Transit/Paratransit Division will contact my healthcare professional to confirm the information provided in this application.

I authorize my healthcare professional to release any/all information required by Macon-Bibb County Transit/Paratransit Division to determine my eligibility.
Applicant's Full Name*
Date of Signature*

MonthDayYear
Should be Empty:

Paratransit Service Eligibility Application

The Paratransit Application

I am NOT the Applicant.

Applicant's Contact Information

Tell us about your Disability.

Your Emergency Contact

Questions About Your Mobility

Healthcare Verification Form

STOP & Read this!