MINI BUS ADA PARATRANSIT ELIGIBILITY APPLICATION
PART B: Professional Verification
DEAR QUALIFIED PROFESSIONAL:
The application form below contains questions to assist you in evaluating the applicant to determine their ability
or inability to ride Finney County Transit fixed-route City Link service unassisted. The applicant is currently
applying for Mini Bus ADA Complementary Paratransit Service and has 21 days from the day they first rode the
Mini Bus to complete the application or risk being refused service. Mini Bus service is strictly limited for only
those persons with disabilities requiring assisted transportation services that are unable to utilize City Link fixed-
route service. Mini Bus is a door-to-door demand response service where customers call ahead to schedule
trips from their place of residence to their destination.
Please read the following ADA (Americans with Disabilities Act) definition of a person with a disability, as it
relates to public transit:
Any person with a disability who is unable, as a result of a physical or mental impairment, to board, ride or
disembark from an accessible vehicle (wheelchair lift equipped) independently or complete transfers without the
assistance of another individual.
and/or
Any person with a disability who has a specific impairment related condition that prevents them from traveling to
and from a bus stop on the public bus fixed route system. Architectural and environmental barriers such as
distance, terrain or weather do not, standing alone, form a basis for eligibility. However, consideration may be
given to the interaction of environmental conditions (terrain and weather) with the individual’s impairment
related condition.
____________________________________________________________________________________
Name of Applicant P.O. Box/Street Address City State Zip code
Is the applicant unable to use City Link fixed-route service as outlined above. Yes _____ No _____
If no, STOP HERE and don’t complete the rest of the application form. Please sign, date and mail this page to
Finney County Transit, 907 N. Tenth, Garden City, KS 67846
____________________________________________________________________________________
Professional Signature Date
_______________________________________________________________________________________
Printed Name Certification/Licensure Phone Number
If you answered yes to the above question, please continue to the next page and answer all of the questions.
Questions regarding this form may be directed to Finney County Transit at (620) 272-3626.
While answering the following questions, keep in mind this information will be one element in the eligibility
determination made by the transit system’s staff/contractor. Please verify the disability claimed by the
applicant, the extent of this disability, and for functional assessments as to the applicant’s ability to perform
activities related to using a fixed route transit service. Your input will be particularly important where applicants
have claimed a “hidden” or “non-visible” disability (e.g. a medical condition such as a cardiac or pulmonary
condition, mental illness, or a joint disease etc.). This verification will also assist in determining the degree of
cognitive capability.
Have you ever examined/evaluated the applicant in the past? Yes _____ No _____
If yes, was examination/evaluation within the last twelve months? Yes _____ No_____
Length of time in treatment/under your care? _______________________
What is the applicant’s specific disability or health condition/limitation and how does it limit or prevent his/her
ability to travel independently or utilize City Link fixed-route service?
___ Certified Legally Blind
___ Loss or inability to use one or more limbs
___ Severe effects of stroke
___ Paralysis affecting mobility, speech, vision or memory
___ Severe arthritis
___ Autoimmune disorders, for example, Lupus or Scleroderma etc.
___ Severe cardiac and/or respiratory impairment affecting strength and/or endurance
___ Severe emotional disorder (may require an escort)
___ Developmental disabilities, for example, mental retardation, cerebral palsy, epilepsy, autism or neurological
disorder, etc.
___ Hearing loss accompanied by an inability to understand speech with/without a hearing aid
___Other (Please explain the medical diagnosis and then describe the disability or health condition/limitation)
Use other side of page if necessary
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Date of onset?______________________________
Is the applicant’s disability:
Permanent Yes _____ No _____
If temporary, how long? ____________________________
Is this applicant’s disability:
Seasonal ______ If so, which season(s)?_______________________
4. What mobility aids does the applicant utilize? Check all that apply.
Manual Wheelchair ____ Electric Wheelchair ____
Powered Scooter ____ Cane ____
Walker ____ White Cane ____
Service Animal ____ Crutches ____
Oxygen ____ Other (please list) ______________________________
Does the applicant require a Personal Care Attendant (PCA) when traveling on transit vehicles? (Riders must
provide their own PCA) Never _____ Sometimes _____ Always _____
If a PCA is needed, explain why.
________________________________________________________________________________________
______________________________________________________________________
Which of the following weather conditions impact the applicant’s disability or health condition such that it
prevents him/her from independently getting to and/or from a bus stop?
Indicate: Heat _____ Cold _____ Humidity _____ Snow _____ Ice _____
Pollution/Allergies_____ Other_____ N/A ____
What specific weather condition prevents this person from getting around on his/her own? How so?
________________________________________________________________________________________
________________________________________________________________________________________
Does rough terrain make it hard for the applicant to travel? Yes ______ No _______ Sometimes ________
If you answered Yes or Sometimes, describe your definition of rough terrain and how that makes it difficult for
the applicant to travel.
________________________________________________________________________________________
________________________________________________________________________________________
Is applicant able to: (Check all that apply)
___Understand and/or process information
___ Ask for or follow written or oral information, such as schedules
including TDD, audio tape or voice?
___ Figure out the correct fare?
___ Follow instructions in an emergency?
___ Recognize his/her destination while on the bus?
___ Once he/she gets off the bus, locate and reach his/her destination?
___ Cross a busy intersection?
___ Find his/her way between familiar locations?
___ Signal the bus driver to get off the bus at familiar stop and then get off the bus?
Assume the driver calls all stops
___ Grasp coins, passes, and handles?
___ Communicate addresses, destinations, and telephone numbers on request?
___ Deal with unexpected situations or unexpected changes in routine, e.g., route changed due to road
construction, regular bus stop closed?
___ Go up and down steps?
Your Name and Title:_________________________________________________
Certificate/Licensure: _________________________________________________
Office Address: _____________________________________________________
_____________________________________________________
Office Telephone Number: _____________________________________________
Signature __________________________________ Date: _________________
Qualified professional please forward the signed original to Finney County Transit, 907 N. Tenth, Garden City,
KS 67846 as soon as possible. You may also fax a copy to (620) 271-6370 to expedite the process, but the
signed original must be forwarded to the Finney County Transit. Thank you for your cooperation.
Authorization Form for Disclosure of Protected Health Information
I ______________________________________________authorize the qualified professional
(Printed Name of Patient)
________________________________________________ completing Part B (Qualified Professional
(Printed Name and Title of Qualified Professional)
Verification) of the Mini Bus Paratransit Eligibility Application on my behalf, to release this information about my
disability and abilities to use the accessible City Link fixed-route bus service to representatives of the Finney
County Transit for their review as well as any supporting or other pertinent information about my health or
medical condition to assist Finney CountyTransit solely for the purpose of determining eligibility for Mini Bus
ADA complementary paratransit service. I understand that all medical information about my disability will be
kept strictly confidential.
I understand that I do not have to sign this authorization in order to be considered for services, but I understand
that no weight will be given to medical conditions claimed which cannot be verified. In fact, I have the right to
refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it
may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy
Rule. I have the right to revoke this authorization in writing except to the extent that Finney County Transit has
acted in reliance upon this authorization. My written revocation must be submitted to Finney County Transit,
907 N. Tenth, Garden City, KS 67846
___________________________________________________ _________________________
Signature of Applicant or Legal Guardian Date
Legal Guardian’s Relationship to Applicant:_________________________________________________
Printed Name of Legal Guardian, if applicable:_______________________________________________
Printed address & telephone number of Legal Guardian: _______________________________________
____________________________________________________________________________________
Applicant / guardian must be provided with a signed copy of this authorization form.
NOTE: If only able to make a “mark” for your signature, simply make your mark and then have someone act as
a witness by signing their name above or beside yours. May be signed by a “legal guardian” or “power of
attorney” only if a copy of documentation showing your legal authority to act and sign on applicant’s behalf is
also provided. DOCUMENTATION IS NOT NECESSARY FOR THE PARENT OF A MINOR CHILD.
Qualified professional please fax a copy of this signed release form to (620) 271-6370. Thank you for your
cooperation.
(to print application, right click on the document and click print)