www.rtachicago.org www.rtachicago.org DISABLED PERMIT APPLICATION DISABLED PERMIT APPLICATION TO BE COMPLETED BY A LICENSED MEDICAL PROFESSIONAL Applicants do not qualify if their sole condion is pregnancy, obesity, impairment due to drugs/ alcohol abuse, or a dysfuncon that can be controlled through medicaon. Please check the appropriate box. Applicant is eligible for a Reduced Fare Permit if one of the following criteria listed below applies: If applicant meets the eligibility criteria, please aach a statement on your professional leerhead or prescripon form (please type or print) nong the diagnosis of the applicant and describing in detail why he/she meets the eligibility criteria. Photocopies and form leers are not acceptable. This statement is required in order to process this applicaon. Check One: ❑ Physician ❑ Psychiatrist ❑ Optometrist ❑ Audiologist ❑ Chiropractor ❑ Psychologist ❑ Physician Assistant ❑ Nurse Praconer NAME (PLEASE PRINT) BUSINESS ADDRESS CITY STATE ZIP CODE PATIENT’S NAME (PLEASE PRINT) D.O.B WRITE YOUR LICENSE NUMBER: - STATE This number will be verified by your State Department of Professional Regulaon. Please note temporary numbers are not accepted. Informaon falsely presented on this applicaon by a licensed medical professional may result in their prosecuon to the fullest extent allowable under the law. In addion, any falsificaon of informaon on this form may be considered grounds for revocaon, suspension, reprimand or other disciplinary acon. RTA reserves the right to (1) contact the licensed medical professional to verify the informaon provided, (2) make the final determinaons on an applicant’s eligibility for a Reduced Fare Permit and (3) have an applicant submit to a second exam by a licensed medical professional selected by the RTA. I hereby cerfy to the best of my knowledge the informaon on this applicaon form is true and correct. Date: Signature: ❑ A physical disability, including, but not limited to: respiratory, cardiac, or neurological disabilies, a person receiving dialysis, living with AIDS, MS, or a chronic progressive debilitang disease ❑ A disability that effects mobility, including but not limited to: people who are non-ambulatory, use a mobility aid, have arthris or an amputaon ❑ A person who is blind or visually impaired ❑ A person who is deaf or has a hearing disability (Audiologist approval only) ❑ An intellectual disability or developmental disability ❑ A psychiatric disability that is chronic in nature Please indicate the duraon of disability: ❑ 6 mths ❑ 9 mths ❑ 1 year ❑ 4 years ❑ Applicant’s impairment does not meet any of the funconal limitaons listed above. Therefore, I cannot cerfy that the applicant’s impairment, at this me, meets the criteria for receiving the RTA Reduced Fare Permit. ATTACH HERE RTA Disabled Ride Free Permit Low-income disabled individuals age 64 and younger who are enrolled in the Benefit Access Program administered by the Illinois Department on Aging (DOA) may apply for a Ride Free Permit for free rides on RTA fixed route bus and rail services provided by CTA, Pace, and Metra. You must be enrolled in the Benefit Access Program before you can be approved for a Ride Free Permit. For more informaon about the DOA Benefit Access Program, call 1-800-252-8966 or visit www.cbrx.il.gov. Disabled Reduced Fare Permit Disabled individuals age 64 and younger who are not qualifed for the low-income Benefit Access Program are eligible to ride RTA fixed route bus and rail services provided by CTA, Pace, and Metra at a reduced fare with a valid Reduced Fare Permit. Applicaon Instrucons Complete the applicaon on the reverse side of this page to apply for a Ride Free Permit or a Reduced Fare Permit and send to the RTA in the envelope provided or mail to the address below along with a copy of your current government- issued ID card such as a driver’s license, state ID card, passport, or alien registraon card. You must include a 1-1/2” by 1-1/2” color photo that clearly shows your face. If you are applying for the Disabled Reduced Fare Permit, proof of your disability must also be included. IF APPROVED, YOU WILL RECEIVE YOUR RIDE FREE PERMIT OR REDUCED FARE PERMIT WITHIN 3-4 WEEKS. RTA Customer Service, 69 W. Washington St., Suite LL07, Chicago, IL 60602. Phone: (312) 913 3110 MOVING YOU APPLICATION DISABLED PERMIT