COMPLETING THE CALL-A-BUS APPLICATION
There are 2 parts to this application:
PART 1 - APPLICANT INFORMATION
- Requests information about the applicant, including any special needs or limitations which the individual may have.
- Must be filled out completely, either by the applicant or by someone who is assisting the applicant.
- Contains a HIPAA Authorization on page 12. This must be completed by the applicant or by the applicant’s Power of Attorney.
PART 2 - HEALTHCARE PROFESSIONAL VERIFICATION OF FUNCTIONAL DISABILITY
- Must be filled out completely, and by only one individual.
- Please read page 13 to determine who may complete Part 2.
- The individual who completes Part 2 must also sign where indicated on page 19.
NOTE: For your convenience, following Part 2 there is a checklist which you can use to be sure that you have filled out this application completely.
Following the checklist, there is information regarding the re-certification process, plus the appeals process in the event that you do not agree with the determination of your eligibility status.