ADRC Transportation Application

Transportation Application
I am*

Ambulatory (I CAN enter or exit an automobile)Non-Ambulatory (I canNOT enter or exit an automobile; I use a wheelchair or scooter)

BASIC INFORMATION
Applicant First Name*
Applicant Last Name*
Applicant Middle Name
Date of Birth*

MonthDayYear
Date
Date Submitted

MonthDayYear
Date
Age
Gender*

MaleFemaleSelf-Describe
Address*
City*
State*
Zip*
Email
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.

OPTIONAL INFORMATION
Primary Language
Race
Ethnic Origin

RIDELINE FARE DETERMINATION
Financial Information

I do not wish to divulge my financial information. I agree to pay the following fare: One-way trip within the same community: $10.55 One-way trip from one community to another $13.75 One-way trip to an adjoining County $22.00 (Available ONLY with prior approval for medical and ONLY if service is NOT available in Waukesha County)I choose to disclose my financial information for the Aging and Disability Resource Center of Waukesha County. The information will only be used to determine my RideLine fares based upon my ability to pay
Passenger Average Monthly Income
Spouse Average Monthly Income
Include your social security, pension, disability, wages, interest/dividends, rental income, and any other income you may receive.
Passenger Average Monthly Medical Expenses
Spouse Average Monthly Medical Expenses
Include medicine, medical supplies, supplemental health insurance premiums, and dental, doctor or hospital bills. DO NOT INCLUDE medical expenses paid for by Medicare, Medicaid, or other insurance.
Passenger Total Liquid Assets
Spouse Total Liquid Assets
Include savings, checking, CDs, IRAs, stocks, bonds, trusts, and annuities.

DISABILITY DESIGNATION FORM
If you are between the ages of 18 to 59, please print and complete this form. Click ellipses (...) at the right side of the form to print. Please return this completed form to: Aging and Disability Resource Center of Waukesha County Human Services Center 514 Riverview Avenue Waukesha, WI 53188-3631 OR FAX to (262) 896-8273 OR EMAIL to HHSADRCTransportation@waukeshacounty.gov
Attach Disability Designation Form

Cancelof

SIGNATURE
Privacy Policy*

The information you are being asked to provide is needed to determine if you are eligible to receive services and to comply with federal reporting requirements. This information will be stored in a secure electronic database and will not be used for any other purpose. Your information may be shared with the transportation providers that the ADRC contracts with for transportation services. This information will not be sold to anyone. You have the right to review your electronic record and request changes to assure accuracy. Failure to provide this information may result in a denial of some services. If you have questions regarding this, please ask the ADRC staff.
Waukesha County HHS Notice of Privacy Practices

Waukesha County ADRC Customer and Staff Rights and Responsibilities
ADRC Conflict of Interest Disclosure*

The primary purpose of the ADRC is to provide the customer with unbiased information about benefits, programs, resources, and services that will meet their needs. This includes sharing information with customers about agencies that provide needed services. The ADRC may operate programs that provide direct services to customers. The ADRC cannot attempt to influence customers: •For financial gain or other self-interests. •In the interest of any service or program provider , including the ADRC itself. The ADRC is prohibited from using revenue generated from direct service programs to support ADRC specialist services, including information and assistance, long-term care options counseling, and enrollment counseling. The privacy of your protected health and/or confidential information is important to us. By my signature below, I acknowledge that WCDHHS ADRC offered or that you have received a copy of the Waukesha County Department of Health and Human Services Notice of Privacy Practices Regarding Health Information which explains how your health information and/or confidential information will be used and the ADRC of Waukesha County ADRC Customer and Staff Rights and Responsibilities form, and I have been provided with the opportunity to discuss my concerns and questions.
Authorization*

This information is true and complete to the best of my knowledge. I authorize the use of this information by representatives of the Aging and Disability Resource Center of Waukesha County for the purposes of fare determination. I understand this information will remain confidential.
Representative

This application is being completed by a person other than the applicant.
Representative Name

First NameLast Name
Relationship to Applicant
Representative Phone
Please enter a valid phone number.
Representative Email
example@example.com
Representative Date Signed

MonthDayYear
Date
Signature of Person Completing Form*

Clear
Applicant Date Signed

MonthDayYear
Date
Should be Empty: