Parts A and B: Applications for SunDial Paratransit Service

Date

MonthDayYear
Date
Application for SunDial Paratransit Service
Informational Sheet
Gracias por su interés en la elegibilidad para el servicio de paratransporte ADA de SunLine Transit. SunLine ofrece múltiples opciones de transporte público para personas con discapacidades. La elegibilidad para estos servicios se basa en la capacidad funcional de una persona para utilizar el servicio de autobuses de ruta fija de SunLine (SunBus).

SunLine opera servicios de autobuses de ruta fija que transportan diariamente a personas con discapacidades físicas, cognitivas y visuales. Todos los autobuses de SunLine están equipados con características accesibles según la ADA, como autobuses de piso bajo, elevadores/rampas, anuncios de audio, áreas de asientos prioritarios para personas con discapacidades, señalización mejorada, autobuses con sistema de inclinación y pasamanos.

SunLine también ofrece el servicio de paratransporte SunDial para clientes con discapacidades que no pueden usar funcionalmente el servicio de autobuses de ruta fija de SunLine (SunBus). Si usted no puede usar el servicio de autobuses de ruta fija debido a una limitación funcional, puede ser elegible para el servicio SunDial. SunDial es un servicio de paratransporte público para clientes con discapacidades que no pueden utilizar el sistema de autobuses de ruta fija.

Factores como diagnóstico, edad, distancia a la parada de autobús, falta de servicio de autobús, autobuses llenos, incapacidad para conducir, situación financiera, inconveniencia o incomodidad no son la base exclusiva para determinar la elegibilidad del servicio SunDial.

SunDial se proporciona de acuerdo con la Ley para Personas con Discapacidades (ADA) y es un servicio de transporte público compartido, de reserva anticipada, de origen a destino. En cumplimiento con la ADA, SunDial es comparable al sistema de autobuses de ruta fija de SunLine (SunBus), incluyendo características del servicio como puntualidad, tiempos de viaje y cobertura del área de servicio (¾ de milla de una ruta fija de SunLine).
CÓMO APLICAR:
1. Revise la información de elegibilidad proporcionada en esta solicitud ADA.Si
2. cree que califica para los servicios de paratransporte ADA:
  a. Complete toda la Parte A de la solicitud de paratransporte ADA.
  b. Firme la solicitud.
  c. Haga que un profesional médico familiarizado con su condición de salud, discapacidad y sus capacidades y limitaciones funcionales complete el Formulario de Certificación del Proveedor de Atención Médica – Parte B de la solicitud.
🔹 IMPORTANTE: La verificación médica debe completarse dentro de los 60 días anteriores a la solicitud (no puede ser firmada por el proveedor de atención médica más de 60 días antes de entregarla a SunLine Transit Agency).

Cuando tenga ambas secciones completadas, envíelas por correo a:

SunLine Transit Agency
c/o Eligibility
32-505 Harry Oliver Trail
Thousand Palms, CA 92276

Antes de iniciar esta solicitud y el proceso de certificación, entiendo que toda la información proporcionada debe ser verdadera, precisa y correcta. Certifico que, según mi mejor conocimiento, la información proporcionada en esta solicitud es correcta. El propósito de esta solicitud es determinar si soy elegible para utilizar los servicios de paratransporte o, en algunos casos, si puedo usar el servicio de autobuses de ruta fija de SunLine (SunBus). Entiendo que proporcionar información falsa puede resultar en la pérdida de los servicios de paratransporte, así como en sanciones según la ley.

Una solicitud incompleta no será procesada y será devuelta al solicitante, lo que puede causar retrasos en el proceso. Las Partes A y B deben enviarse juntas para que la solicitud sea considerada. Todas las preguntas deben responderse de manera clara y legible. SunLine se comunicará con el proveedor de atención médica que completó la Parte B para verificar la información proporcionada.

Instrucciones Importantes para la Solicitud

Para completar el proceso de solicitud para el Servicio de Paratransporte SunDial, siga estos pasos:
- Descargue e imprima la Parte B – La Certificación del Proveedor de Atención Médica (Parte B) debe ser completada por su proveedor de atención médica.
- Lleve la Parte B a su médico – Entregue el formulario impreso a su proveedor de atención médica y solicite que lo complete.
- Pida a su proveedor de atención médica que le envíe la solicitud completada por correo – Su proveedor debe enviarle directamente la Parte B completa por correo a su domicilio.
- Envíe las Partes A y B juntas – Una vez que reciba la Parte B completada, debe enviar por correo tanto la Parte A como la Parte B juntas para que podamos comenzar a procesar su solicitud.
⚠️ IMPORTANTE: No envíe la Parte A sin la Parte B y no pida a su proveedor de atención médica que envíe la Parte B sin la Parte A. Ambas partes deben enviarse juntas para evitar retrasos en el procesamiento de su solicitud.
Thank you for your interest in SunLine Transit ADA Paratransit Eligibility. SunLine offers multiple public transportation options for individuals with disabilities. Eligibility for these services is based on a person’s functional ability to use SunLine’s fixed-route bus service (SunBus).

SunLine operates fixed-route bus services that transport individuals with physical, cognitive, and visual disabilities daily. All SunLine buses are equipped with ADA-accessible features, including low-floor buses, lifts/ramps, audio announcements, designated priority seating areas for individuals with disabilities, enhanced signage, kneeling buses, and handrails.

SunLine also provides SunDial Paratransit Service for customers with disabilities who are functionally unable to use SunLine's fixed-route bus service (SunBus). If you are unable to use the fixed-route bus system due to a functional limitation, you may qualify for SunDial service. SunDial is a public paratransit transportation service designed for individuals with disabilities who cannot use the fixed-route bus system. Concerns such as diagnosis, age, distance to a bus stop, lack of bus service, overcrowded buses, inability to drive, financial situation, inconvenience, or discomfort are not the sole basis for determining SunDial eligibility.

SunDial is provided in accordance with the Americans with Disabilities Act (ADA) and is an origin-to-destination, shared ride, advanced reservation public transit service. In compliance with ADA regulations, SunDial is comparable to SunLine’s fixed-route bus system, including on-time performance, travel time, and service area (¾ mile from a regular SunLine fixed-route bus stop).

HOW TO APPLY:
1. Review the eligibility information provided in this ADA application.
2. If you believe you qualify for ADA paratransit services:
  a. Complete all of Part A of the ADA paratransit application.
  b. Sign the application.
  c. Have a medical professional familiar with your health condition, disability, and functional abilities complete the Health Care Provider Certification Form – Part B of the application.
🔹 Note: The medical verification must be completed within 60 days prior to applying. (It cannot be signed by the health care provider more than 60 days before submitting it to SunLine Transit Agency.)

Once both sections are completed, mail the full application to:

SunLine Transit Agency
c/o Eligibility
32-505 Harry Oliver Trail
Thousand Palms, CA 92276

Before I start this application and the certification process, I understand all information providedmust be true, accurate, and correct. I hereby certify that, to the best of my knowledge, informationgiven in this application is correct. The purpose of this application is to determine if I am eligible to use paratransit services, or if at times, I can ride the SunLine fixed-route bus service (SunBus). I understandthat falsification of information could result in a loss of paratransit services as well as a penaltyunder the law.

Important Application Instructions

To complete the application process for the SunDial Paratransit Service, please follow these steps:
- Download and print Part B – The Health Care Provider Certification (Part B) must be completed by your healthcare provider.
- Take Part B to your doctor – Provide the printed form to your healthcare provider and request that they complete it.
- Have your healthcare provider mail the completed application back to you – Your provider must mail the completed Part B directly to your home address.
- Submit both Part A and Part B together – Once you receive the completed Part B, you must mail both Part A and Part B together so we can begin processing your application.
⚠️ IMPORTANT: Do not submit Part A without Part B, and do not ask your health care provider to submit Part B without Part A. Both parts must be submitted together to avoid delays in processing your application.
PART A: Applicant Information and Release

Personal Data
Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Date
Home Phone:
Mobile Phone:
Other Phone:
Email Address:*
example@example.com - Using an email account will allow for a quicker response; however, it is the applicant's responsibility to regularly check their email for updates and notifications regarding their application.
Do you require TDD services?*

YesNo
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Gate Code:
Name of Apartment Complex/Community:
We request the apartment complex or community name to ensure accurate location details for transportation services, making it easier to identify pickup and drop-off locations within larger residential areas.
Is your Home address the same as your Mailing address?
Mailing Address:

Street Address

Street Address Line 2

CityState

Zip Code
Recertification:New Application:
SunDial ADA Number:
Exp. Date:

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

First NameLast Name
Phone:*
Other Phone:*
Relationship:*
Application for SunDial Paratransit Service
Transit Usage
1. Do you currently use fixed-route (large public) buses*

YesNoSometimes
2. When was the last time you rode the fixed-route bus?

MonthDayYear
Date
I do not know.
3. How frequently do you ride the fixed-route bus?
4. Which fixed-route bus routes do you currently use?
5. Have you ever had travel training to learn how to travel around the community and/or on how to use fixed-route buses?*

YesNo
6. Would you like information about travel training to use the fixed-route*

YesNo
Disability/Health Condition Information
All questions must be answered.
7. Please describe the disability or health condition which prevents you from using fixed-route buses.
8. Is this a temporary disability or health condition?*

YesNo
9. If yes, how long you do expect it to prevent you from using fixed-route bus service?
Months
Application for SunDial Paratransit Service
10. Are you currently receiving any treatment?*

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

MedicationsPhysical TherapyChemotherapyRadiation TherapyDialysisPsychotherapyNon-weight Bearing ImmobilizationSurgeryRehabilitationWeight Bearing ImmobilizationConvalescenceOther
11. How long will you be receiving treatment?*

< 3 months3-6 months6-9 months9-12 months> 12 monthsUnknown duration
12. 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
13. Do you live in an assisted living facility or nursing facility?*

YesNo
14. Do you ever need to bring someone with you to help you when you travel (a “personal care assistant” or “personal attendant”)?*

YesNo
15. Do you use any mobility aids or equipment? (check all that apply)

Powered/Electric WheelchairManual WheelchairPower ScooterWalkerCaneCommunication BoardProsthesisPortable Oxygen In CartService AnimalWhite CanePortable Oxygen In BagCrutchesBraceNoneOther
Type of Brace:
16. If you use a wheelchair or scooter, what is the width and length?
Width:
Inches
Length:
Inches
17. If you use a wheelchair or scooter, what is the total weight of your mobility device when you are using it?
Weight:
If your wheelchair or scooter is larger than 30 inches wide, 48 inches long and 600 pounds when occupied, the SunLine paratransit vehicle may be unable to accommodate your trip.
Application for SunDial Paratransit Service
Transit Skills
Please read the following statements and check those which best describe your abilities to use fixed-route buses (SunBus) (check all that apply). At least one box needs to be checked.

I can get to and from bus stops if the distance is not too great.I can ride buses when I am feeling well. There are other times, when my disability or health condition worsens, that I cannot ride the buses.I have a disability or health condition that prevents me from riding the buses and if the weather is very hot or cold.My disability or health condition makes it impossible to travel when there is snow or ice on the ground.I can get to and from bus stops only if there are curb cuts and sidewalks.I can get to and from bus stops and light only if there are no hills.I have difficulty understanding or remembering all the things I would have to do to use the buses.I can use the buses if it is someplace that I go all of the time.I can never use buses by myself.I am not sure if I can use buses.I am not able to use buses for other reasons.
If you checked any of the above boxes, please explain:
Functional Skills

The following questions will give us more information about your functional abilities. Please select Always (A), Sometimes (S), or Never (N) in response to the following questions and provide an explanation.

Without the help of someone else can you:
Ask for and understand written or spoken instructions?*

ASN
If Sometimes or Never, please explain:
Stand for 15 minutes if there is no place to sit?*

ASN
If Sometimes or Never, please explain:
Step on and off a sidewalk from a curb?*

ASN
If Sometimes or Never, please explain:
Application for SunDial Paratransit Service
Walk up and down three steps if there is a handrail?*

ASN
If Sometimes or Never, please explain:
Walk on uneven surfaces?*

ASN
If Never, please explain:
Stand on a moving bus if there is a handrail?*

ASN
If Never, please explain:
Transfer from one bus to another?*

ASN
If Never, please explain:
Under the best conditions, what is the farthest that you can travel outdoors (using your mobility aid if you use one without the help of another person?*

< 1 block1-4 blocks> 4 blocks
Please provide any other information about your disability or health condition that would help us better understand your travel abilities
Certification

I hereby certify that, to the best of my knowledge, information given in this application is correct. The purpose of this application is to determine if I am eligible to use paratransit services (SunDial), or if I can ride the SunLine fixed-route buses (SunBus). I understand that falsification of information could result in a loss of paratransit services as well as a 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. I understand that intentionally providing false or misleading information or a refusal of an in-person assessment is grounds for a determination of ineligibility for SunDial services and benefits. I agree to notify SunLine if my condition changes, if I am using a new mobility device, or if I no longer need to use ADA paratransit service.
Applicant/Responsible Party Signature

Clear
Date

MonthDayYear
Date
Application for SunDial Paratransit Service
Authorization for Release of Information
I First Name* Last Name* authorize my health care professional to release any and all information about my disability or health condition and its effect on my ability to travel on the SunLine fixed-route system (SunBus) (Part B). I understand that I may revoke this authorization at any time. I understand that SunLine Staff may contact the health care professional who completed the verification attached to this application, in order to confirm this information. I understand that all medical information will be kept strictly confidential.
Applicant/Responsible Party Signature:*

Clear
Date*

MonthDayYear
Date
If someone assisted in completing this application, please provide the following information:
Print Name
Agency (if applicable)
Relationship to Applicant
Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Other Phone
Signature

Clear
Date

MonthDayYear
Date
Are you a Health Care Provider?*
Do you have the Health Care Provider Certification (Part B)?*
Health Care Provider (Print Name)*
Institution/Facility/Agency name*
Health Care Provider Phone:*
Health Care Provider Email*
example@example.com
Please upload the Health Care Provider Certification (Part B) to start the process. Note: Part B needs to be completed by a health care provider. You can scan or take pictures of the Part B and upload them. Make sure the pictures have good quality/resolution. Parts A and B need to be together to start the process. *

If Part B is not completed by a health care provider, the application will be denied. I understand that SunLine Staff may contact the health care professional who completed the verification attached to this application, in order to confirm this information.
Cancelof
Please Download/print the Health Care Provider Certification (Part B) and take it to your Health Care Provider. You can save Part A and finish the process as soon as you have Part B. Have your health care provider mail the completed application to you. Once you receive it, you must mail both Parts A and B together or upload Part B in this application to complete the process. Do you know your health care provider's email address? If so, you can send Part A along with Part B to your health care provider. Parts A and B need to be together to start the process. IMPORTANT: Part A and B need to be together to start the process.
Part B: Health Care Provider Certification

All information must be filled out
Thank you for your interest in SunLine Transit ADA Paratransit Eligibility. SunLine offers multiple public transportation options for individuals with disabilities. Eligibility for these services is based on a person’s functional ability to use SunLine’s fixed-route bus service (SunBus).

SunLine operates fixed-route bus services that transport individuals with physical, cognitive, and visual disabilities daily. All SunLine buses are equipped with ADA-accessible features, including low-floor buses, lifts/ramps, audio announcements, designated priority seating areas for individuals with disabilities, enhanced signage, kneeling buses, and handrails.

SunLine also provides SunDial Paratransit Service for customers with disabilities who are functionally unable to use SunLine's fixed-route bus service (SunBus). If you are unable to use the fixed-route bus system due to a functional limitation, you may qualify for SunDial service. SunDial is a public paratransit transportation service designed for individuals with disabilities who cannot use the fixed-route bus system. Concerns such as diagnosis, age, distance to a bus stop, lack of bus service, overcrowded buses, inability to drive, financial situation, inconvenience, or discomfort are not the sole basis for determining SunDial eligibility.

SunDial is provided in accordance with the Americans with Disabilities Act (ADA) and is an origin-to-destination, shared ride, advanced reservation public transit service. In compliance with ADA regulations, SunDial is comparable to SunLine’s fixed-route bus system, including on-time performance, travel time, and service area (¾ mile from a regular SunLine fixed-route bus stop).

HOW TO APPLY:
1. Review the eligibility information provided in this ADA application.
2. If you believe you qualify for ADA paratransit services:
  a. Complete all of Part A of the ADA paratransit application.
  b. Sign the application.
  c. Have a medical professional familiar with your health condition, disability, and functional abilities complete the Health Care Provider Certification Form – Part B of the application.
🔹 Note: The medical verification must be completed within 60 days prior to applying. (It cannot be signed by the health care provider more than 60 days before submitting it to SunLine Transit Agency.)

Once both sections are completed, mail the full application to:

SunLine Transit Agency
c/o Eligibility
32-505 Harry Oliver Trail
Thousand Palms, CA 92276

Before I start this application and the certification process, I understand all information providedmust be true, accurate, and correct. I hereby certify that, to the best of my knowledge, informationgiven in this application is correct. The purpose of this application is to determine if I am eligible to use paratransit services, or if at times, I can ride the SunLine fixed-route bus service (SunBus). I understandthat falsification of information could result in a loss of paratransit services as well as a penaltyunder the law.

Important Application Instructions

To complete the application process for the SunDial Paratransit Service, please follow these steps:
- Download and print Part B – The Health Care Provider Certification (Part B) must be completed by your healthcare provider.
- Take Part B to your doctor – Provide the printed form to your healthcare provider and request that they complete it.
- Have your healthcare provider mail the completed application back to you – Your provider must mail the completed Part B directly to your home address.
- Submit both Part A and Part B together – Once you receive the completed Part B, you must mail both Part A and Part B together so we can begin processing your application.
⚠️ IMPORTANT: Do not submit Part A without Part B, and do not ask your healthcare provider to submit Part B without Part A. Both parts must be submitted together to avoid delays in processing your application.
Part B: Health Care Provider Certification

All information must be filled out
Your patient First Name* Last Name* has requested eligibility for SunDial Paratransit Service. SunDial is an origin to destination, shared ride paratransit service for people whose disabilities or health conditions prevent them from riding the fixed route accessible transportation system all, or part of the time. As the applicant’s healthcare provider, you are uniquely qualified to clarify the applicant’s functional abilities and limitations to ride the SunLine fixed route bus system. In order to determine this applicant’s functional abilities, we require you, the healthcare provider, to complete and certify all of the following sections. Please detail how the applicant’s disability(ies) or health condition(s) impact his or her ability to board, navigate, and travel independently on the accessible fixed route system. Please be as specific as possible.
Health Care Provider (please print):*
Institution/Facility/Agency Name:*
State Issued:*
Specialization*
Address*

Street Address

Street Address Line 2

City/State/ZipState

Zip Code
Phone*
Email Address*
example@example.com - Using an email account will allow for a quicker response; however, it is the applicant's responsibility to regularly check their email for updates and notifications regarding their application.
Part B: Health Care Provider Certification
All information must be filled out.
1. Written diagnosis(es) and ICD-9CM and/or DSM Code(s)
2. How long have you been treating the patient?
3. When was the last time you saw the patient?

MonthDayYear
Date
4. What is the expected duration of the disability?*

Short TermLong Term
Short Term: Conditions lasting at least 90 days but are likely to improve within one year
Long Term: Conditions with absolutely little expectation of improvement
5. In your opinion, does this applicant’s disability(ies) prevent him or her from independently using the accessible SunLine fixed route bus service (SunBus)?*

Yes (Answer question 6, if left blank, the application will be denied)No
6. If yes, explain how the disability or health condition impacts the applicant’s ability to travel independently on the accessible SunLine fixed route bus system (SunBus):
(Answer question 6, if left blank, the application will be denied)
Part B: Health Care Provider Certification
All information must be filled out.
16. Do you use any mobility aids or equipment? (check all that apply)

Powered/Electric WheelchairManual WheelchairPower ScooterWalkerCaneCommunication BoardProsthesisPortable Oxygen In CartService AnimalWhite CanePortable Oxygen In BagCrutchesBraceNoneOther
Type of Brace
8. If this applicant is currently on medication(s), will the side effects significantly reduce or hinder his/her ability to independently ride the accessible SunLine fixed route bus service?*

YesNoN/A
9. If you selected yes, please explain how the side effects would hinder their ability to use the accessible SunLine fixed route bus service
For questions 10-22, select Yes (Y), No (N), or Sometimes (S If you answer Yes or Sometimes to questions 10-22, elaborate on how it prevents the applicant from using accessible SunLine fixed route bus service:
10. Would temperature extremes affect this applicant’s ability to ride fixed route bus service?*

YNS
Please Explain:
11. Would ice and/or snow affect this applicant’s ability to ride fixed route bus service transit?*

YNS
Please Explain:
12. Would poor air quality affect this applicant’s ability to ride fixed route busservice?*

YNS
Please Explain:
13. Does this applicant have any challenges with balance?*

YNS
Please Explain:
14. Does this applicant have any challenges with memory?*

YNS
Please Explain:
15. Does this applicant have any challenges with breathing?*

YNS
Please Explain:
16.Does this applicant have any challenges with strength and endurance?*

YNS
Please Explain:
Part B: Health Care Provider Certification
All information must be filled out.
17. Does this applicant have any challenges with ambulating on hills?*

YNS
Please Explain:
18. Are there any visual impairments that would affect this applicant’s ability to ride fixed route bus service?*

YNS
Please Explain:
19. Are there any hearing impairments that would affect this applicant’sability to ride fixed route bus service?*

YNS
Please Explain:
20. Does this applicant exhibit any inappropriate social behaviors? Y N SPlease Explain:*

YNS
Please Explain:
21. Do you have safety concerns for this applicant in using a bus bythemselves?*

YNS
Please Explain:
22. Does this applicant require a Personal Care Attendant when traveling?*

YNS
Please Explain:
23. In your medical opinion, what other factors related to the applicant’s disability(ies) affect his/her ability to ride the accessible SunLine fixed route service?*
Date

Clear
Date

MonthDayYear
Date
Should be Empty:

Application for SunDial Paratransit Service

Informational Sheet

PART A: Applicant Information and Release

Application for SunDial Paratransit Service

Transit Usage

Disability/Health Condition Information

Application for SunDial Paratransit Service

Application for SunDial Paratransit Service

Transit Skills

Application for SunDial Paratransit Service

Application for SunDial Paratransit Service

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification