Physician's Portal

for the Reduced Fare Assistance Program

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Disabled reduced fare

Submit Application

"*" indicates required fields

Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Date of Birth*

I use the following mobility device:

Please select which applies to the applicant:*

In order to qualify for the E&D fare, the applicant must be at least 65 years old or have a disability that limits their mobility or self-care. Please select the one that applies to the applicant. WE MUST HAVE DOCUMENTATION SUPPORTING APPLICANT'S AGE OR DISABILITY.

Disabled

Please upload supporting documentation.

DISABLED - Must have mobility limitations or self-care limitations. Please provide a copy of one of the following documentations: SSI award letter, SS Disability award letter or have a licensed physician, health care professional complete the following statement of disability (valid for 2 years or duration of temporary disability).

After review of acceptable documentation a Certificate of Eligibility Card will be issued.

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, doc, docm, docx, dot, dotx, Max. file size: 1,000 MB.

Statement of Disability

Meets ADA Criteria for Mobility or Self-Care Limitations

Physician's Name*

Title*

Physician's Email*

Physician's Phone Number*

Physician's Signature*

Date*

Is the above client's disability temporary?*

Yes

If yes, expected length of temporary disability, until what date:

Name

This field is for validation purposes and should be left unchanged.