Physician's Portal

for the Reduced Fare Assistance Program

Disabled reduced fare

Submit Application

"*" indicates required fields

Name*
Address*
MM slash DD slash YYYY
 
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 - 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
    MM slash DD slash YYYY
    Is the above client's disability temporary?*
    MM slash DD slash YYYY
    This field is for validation purposes and should be left unchanged.