ADRC Transportation Application

Transportation Application
I am
- Applicant Legal First Name
- Applicant Legal Last Name
- Applicant Middle Name
- Date of Birth
  
  MonthDayYear
  Date
- Date Submitted
  
  MonthDayYear
  Date
- Age
- Gender
  
  Self-Describe
- Address
- City
- State
- Zip
- Email
  example@example.com
- Home Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Cell Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Primary Language
- Race
- Ethnic Origin
- Are you a non-driver or limited driver?
- Are you able to enter and exit a vehicle?
- Do you use any portable oxygen, manual wheelchair, powered wheelchair or scooter?
- Select all that apply
- Length
- Width
- Do you have a personal attendant who is required to accompany your travel?
- A “personal attendant” is defined as “a personal aide to the passenger, necessary to facilitate the safe mobility of the passenger.” Note that if anattendant is necessary to provide mobility assistance or supervision to ensure safety beyond the basic door-to-door service provided by the RideLine program,all travels will require an attendant and no rides can be arranged without one. Rider is responsibleto provide, or arrange for, their own attendant.
- Are you able to transfer from a wheelchair or scooter to a seat with little or no assistance?
- Are you receiving Medicaid (Title 19)?
- Are you enrolled in one of the Wisconsin Long Term Care Programs?
- Which one?
- Please provide the name of your Managed Care Organization
- Please provide the name of your IRIS Consultant Agency
- 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)
- 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.
- 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
- 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
- Representative
- Representative Name
  
  First NameLast Name
- Relationship to Applicant
- Representative Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Representative Email
  example@example.com
- Representative Date Signed
  
  MonthDayYear
  Date
- Signature of Person Completing Form
  
  Clear
- Applicant Date Signed
  
  MonthDayYear
  Date
- Should be Empty: