STATEWIDE TRANSPORTATION ACCESS PASS APPLICATION

Dear Applicant,

Enclosed you will find an application for a Statewide Transportation Access Pass. If approved, this pass entitles you to reduced fares offered by the Commonwealth's Regional Transit Authorities while riding on their fixed bus routes.

Upon completion of your application, please mail it to our office at 474 Main St., Greenfield, 01301.
We will not accept faxed copies.

Depending on the nature of your disability, you will be issued either a one-year or a three-year pass.

All applications take approximately 21 days to process. You will receive written notification in the mail. If approved, you will be instructed to bring two forms of identification, $3.00 cash or money order and your notification letter to the FRTA at 474 Main St., Greenfield. The FRTA will take your photo and process your pass while you wait.

Do not hesitate to contact our office at (413) 774-2262 Ext. 103 if you have any questions or need assistance in completing this application.

Commonwealth of Massachusetts/Reduced Fare Program

1. PLEASE PRINT.  COMPLETE PART A BELOW:

PART A:  APPLICANT INFORMATION

NAME:  _________________________________                DATE:  __________

STREET ADDRESS: _______________________________________________

CITY:  _________________________          STATE:_____    ZIP:____________

TELEPHONE: (     ) ______________            RENEWAL:     ___YES___NO

SOCIAL SECURITY NUMBER:  _______________

 DATE OF BIRTH:  __________

2.  COMPLETE PART B BELOW. 
If you are: A Medicare Card Holder, over the age of 60, have an ADA eligibility card, or are a Veteran with a disability
rating of 70% or greater, it is not necessary to have Part C completed.  Simply complete Parts A and B and
submit this application to the FRTA for processing (Go to #4 below).

3.  If you are not in one of the categories mentioned in #2 above, you must bring this application to a licensed/certified
health care professional to complete Part C for health care certification.

Examples of licensed/certified health care professionals include those who are familiar with your disability and are licensed
or certified in their field, such as Medical Doctor, Licensed Social Worker, Psychologist, Audiologist, Registered Nurse,
Psychiatrist.

4. Once this application is completed, return it to the FRTA.  The FRTA will review the information to determine your
eligibility.  You will receive notification within 21 days. 
We will not accept faxed copies.

 

PART B:  TO BE COMPLETED BY APPLICANT

CHECK ONLY ONE OF THE FOLLOWING:

 ____ I AM A MEDICARE CARDHOLDER.  I HAVE ATTACHED A PHOTOCOPY OF MY CARD.  (Please note: MassHealth is not the same as Medicare.  Do not attach a copy of MassHealth card).

 ____ I HAVE AN ADA ELIGIBILITY CARD.  I HAVE ATTACHED A PHOTOCOPY OF MY CARD.

 ____ I AM OVER THE AGE OF 60.  I HAVE ATTACHED A PHOTOCOPY OF MY LICENSE OR OTHER PROOF OF AGE.

 ____ I AM A VETERAN WITH A DISABILITY RATING OF 70% OR GREATER.  I HAVE ATTACHED AN ORIGINAL LETTER FROM THE VA, SIGNED BY A VETERAN'S SERVICES OFFICER, WHICH SPECIFIES MY DISABILITY RATING.

**If you checked one of the above boxes, then you do not need to have Part C completed**

 ____ I DO NOT FALL INTO ANY OF THE ABOVE FOUR CATEGORIES; THEREFORE I HAVE PROVIDED THE FRTA WITH INFORMATION FROM MY LICENSED HEALTH CARE PROFESSIONAL (PART C).

I AGREE TO RELEASE THIS INFORMATION TO THE FRTA FOR THE PURPOSE OF DETERMINING ELIGIBILITY FOR A TRANSPORTATION ACCESS PASS.  THE FRTA RESERVES THE RIGHT TO CONTACT THE LICENSED PROFESSIONAL COMPLETING THIS APPLICATION.

SIGNATURE OF APPLICANT:  ___________________________________________


FOR FRTA USE ONLY:

Name of Applicant:  ________________________                          FRTA


PART C.  TO BE COMPLETED BY A HEALTHCARE PROFESSIONAL

Refer to the attached criteria to answer the questions below and check mark the appropriate responses:

1.   Is the applicant disabled according to at least one of the Criteria listed in the attached?     Yes ___     No ___

If yes, fill in the criteria number 1 - 9 ______

Please define the disability:  _________________________________________________________________

2.   Is the disability a permanent condition?   Yes  ___    No  ___

If no, estimated length of disability (in months)  ____________

3.   Is the applicant, despite his/her disability, able to use the FRTA fixed route bus service?   Yes  ___    No  ___

4.   Which of the following mobility aids or equipment do you use to help you get where you need to go?  (please check all
      that apply).

___ Manual Wheelchair                   ___ Power Wheelchair

___ Power Scooter                         ___ Walker

___ Cane                                        ___ Crutches

___ Prosthetic Device/Brace           ___ Respirator/Oxygen Tanks

___ Guide Cane                              ___ Service Animal (Guide dog, etc..)

___ I do not use a mobility aid              

___ Other (specify):  _______________________________________

5.  In addition to the above, does the applicant require the aid of an attendant when going from the house to
    the curb/vehicle?   Yes ___    No  ___

To the best of my knowledge, the information contained in this form is correct.

Physician or Professional's Signature: _________________________        

Print or Type Name: _______________________________________

Telephone: _____________________  Date: ____________________


Office Address: ___________________________________________

CRITERIA FOR DISABLED INDIVIDUALS TO QUALIFY FOR THE STATEWIDE TRANSPORTATION
ACCESS PASS

1.  Any individual who cannot walk more than 200 feet to a bus route or final destination without the use of a mechanical
     aid (crutches, walker, etc..).

2.  Any individual who uses a wheelchair.

3.  Any individual who has less than 20/20 vision with best correction or a field restriction of 10 degrees or less.
    (Any legally blind applicant must have a certificate of blindness from the Mass Commission for the Blind 800-392-6450).

4.  Any individual who is considered deaf and whose hearing is uncorrectable by use of a hearing aid.

5.  Any individual who cannot walk more than 200 feet to a bus route or final destination because of a neurological,
     muscular-skeletal, pulmonary or cardiovascular disorder.

6.  Any individual who has a developmental disability or an emotional disorder. 
     Eligibility for emotional disorders is as follows:

             6a.  Emotionally disturbed person who is living in a community residence or boarding home and participating
                    in a sheltered workshop or day hospitalization program.

             6b.  Living at home and participating in a sheltered workshop or day hospitalization program.

7.  Any individual who is an amputee.

8.  Any individual who requires kidney dialysis treatment.

9.  Any individual who has a valid Medicare Card (see instructions for Medicare cardholders).

FRTA_________________________________________

Franklin Regional Transit Authority