TD Paratransit Application Form

Space Coast Area Transit's Transportation Disadvantaged (TD) Service Program provides transportation services throughout Brevard County to the elderly, disabled, economically disadvantaged, children at risk, and those with no feasible means of transportation. The TD Paratransit Certification Form explains how an individual's disability prevents him/her from riding Space Coast Area Transit's Fixed Route Bus System. Applications in Braille, large print and on tape are also available upon request.

Applicants are eligible for 21 days of service while their information is being processed for certification. Additionally, applicants are eligible for 21 days of out-of-town-service if they have documented TD Paratransit Certification from another public entity. After an applicant's TD Paratransit eligibility is certified, they will be notified by phone or e-mail. If eligibility is denied, a letter will be mailed to the applicant explaining the reason for denial and advising him/her of the process to appeal.

To apply, please complete and submit the following online TD Application form as well as upload the following to prove eligibility: a Medicare Card, SSD Letter or SSI Award Letter, or a letter from a medical provider and a State ID for proof of age.

Alternatively, you may print and manually complete the TD Application. Please return the signed application, along with either a Medicare Card, SSD Letter or SSI Award Letter, or a letter from a medical provider and a State ID for proof of age, to Space Coast Area Transit at 401 South Varr Ave., Cocoa, FL, 32922. If you have any questions, need assistance with the application, or would like to schedule initial service, please contact Customer Service at (321) 635-7815 ext. 52937 or email email us.

Select Applicant's age:

Under 60

60 and older

Submit

Required fields indicated by *

SECTION A - PERSONAL INFORMATION

Last Name*:

First Name*:

Middle Initial:

Home Address*:

City*:

Sub Division Name:

State*:

Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*:

Mailing Address (if Different):

Phone Number*:

Home:

Work:

Mobile:

Email*:

Date of Birth*:

Male:

Female:

Emergency Contact*:

Relationship*:

Contact's Phone #*:

Home:

Work:

Mobile:

List other family members/dependents who need and are eligible for transportation:

First/Last Name

Date of Birth

Relationship

SECTION B - AVAILABILITY OF OTHER TRANSPORTATION

1. Does applicant own a vehicle?*

Yes

No

Year, Make, Model:

2. State the reason why applicant cannot drive his/her vehicle (e.g. medical, vehicle troubles, etc):*:

3. Transportation service duration requested:*

Permanent

Temporary

4. Does any other member of applicant's household own a vehicle?*:

Yes

No

5. Could any of applicant's household members, family, or friends provide transportation?*

Yes

No

If no, please explain:

6. How is applicant currently being transported to appointments?*:

7. Does applicant live in a facility that can provide transportation?*:

Yes

No

If yes, please provide the facility name?

8. Is applicant enrolled in any other program(s) that will pay for or provide applicant with transportation services?*:

Yes

No

If yes, please provide the name of the program(s):

9. What is the nature of the disability preventing applicant from using Fixed Route Bus Service?*:

10. How does this disability prevent applicant from using Fixed Route Bus Service? Explain.*:

SECTION C - COMMON DESTINATIONS

List all hospitals, doctors, medical facilities, employment, educational and other locations that applicant visits on a regular basis. Use an additional sheet of paper if more space is required.

SECTION D - SPECIAL NEEDS

List any special needs*: Not Applicable Manual Wheelchair Powered Wheelchair Powered Scooter Walker Cane Respirator Service Animal Personal Care Attendant (PCA)

Does applicant have any other needs/conditions (cultural, religious, physical, psychological, etc.) that we need to be aware of in order to transport him/her safely?

Yes

No

If yes, please explain:

SECTION E - CERTIFICATION AND ACKNOWLEDGEMENT

I understand and affirm that the information provided in this application for Non-Emergency Transportation Disadvantaged services is true and correct to the best of my knowledge and will be kept confdential and shared only with medical and transportation professionals involved in evaluating and determining my needs and eligibility for transportation to and from eligible services as well as appointments. I understand that providing false or misleading information or making fraudulent claims or making false statements on behalf of others could constitute a felony under the laws of the State of Florida.

⌫Clear Signature

Applicant's Signature*

Date*

By electronically signing this document, I affirm, under penalty of perjury, that I am the identified signatory and have full knowledge and consent of the terms and conditions. The attached State ID further verifies my signature and authority, and this electronic signature holds the same legal weight as a handwritten signature.

Only signed applications with a copy of a State ID and proof of disability will be processed.

Applicants MUST include one of the following to prove eligibility: a Medicare Card, SSD Letter or SSI Award Letter, or a letter from a medical provider and a State ID for proof of age.

Only signed applications with a Medicare Card, and a valid State Identification Card for proof of age will be processed.

Applicants MUST include a Medicare Card and a State ID for proof of age.

Select and upload one of the following*

Medicare Card

SSD Letter

SSI Award Letter

Letter from a medical provider

Upload applicant's Medicare Card below.*

Drag & Drop your file here

or

Browse Files

Upload applicant’s State ID below.*

Drag & Drop your file here

or

Browse Files

SECTION F: FOR OFFICE USE ONLY – REVIEW RESULTS

Date Received:

New Application: (Y/N) Redetermination:

Date Approved:

Date Denied:

Reason for Denial:

Letter:

Category Type:

Funding: Medicaid (Y/N) TD: (Y/N) New Application: (Y/N)

Submit Print