General Information: Please read carefully. All questions must be answered. Incomplete or unsigned applications will be returned.
List in order of preference
If you answered yes, there must be someone to meet you on all trips you take on Dial-a-Ride. If no one is available at your destination, SMART will call the contact person listed in Part B.
I understand that the purpose of this application is to determine whether I am eligible to use SMART Dial-a-Ride services. I certify that the information in this application is true and correct. I understand that providing false information may result in denial of service as well as penalty under the law. I understand that information I provide will be disclosed only as needed to evaluate eligibility for Dial-a-Ride paratransit, and to provide Dial-a-Ride services if I am determined to be eligible, unless I give other specific authorization. I understand that it may be necessary for me to participate in an in-person evaluation at SMART's expense, to determine my eligibility for Dial-a-Ride services . I understand that SMART may review my current ADA Dial-a-Ride eligibility status at any time whatsoever where circumstances may warrant that I am no longer eligible to receive ADA Dial-a-Ride transportation service.
If someone other than the applicant assisted in completing this application, that person must complete and sign the following :
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I, (Applicant or Patient Name)
to disclose Protected Health Information (PHI) to the SMART Dial-a-Ride (paratransit) Program, 28879 Boberg Road,Wilsonville, OR 97070, for the purpose of assessing whether I am eligible under the Americans with Disabilities Act for SMART's Dial-a-Ride transportation service. Only those persons with disabilities whose disabilities prevent their use of regular SMART bus service are eligible to use Dial-a-Ride service. My PHI may include medical records, diagnostic reports, physical therapy records, and any personal and medical information pertinent to my application for Dial-a-Ride eligibility. If the information to be disclosed contains any of the types of records or information listed below additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed only if I place my initials in the space next to the type
My cancellation of this authorization will not
affect any uses or disclosures made before my request is received. If I do not revoke this
authorization, it will automatically expire in
I understand that I am not legally obligated to sign this authorization and that SMART will not
refuse to accept my application for Dial-a-Ride eligibility based on my refusal to sign this
authorization. I also understand that if SMART is unable to obtain information necessary to
determine my disability or health condition and how the disability or health condition limits or
prevents my use of regular bus services, my application for Dial-a-Ride eligibility may not be
processed or may be denied.
I understand that the information used or disclosed pursuant to this authorization may be subject
to redisclosure and no longer be legally protected. However, I also understand that federal or
state law may restrict redisclosure of HIV/AIDS information, mental health information, genetic
information and drug/alcohol information.
I understand that by signing this statement I am authorizing SMART to provide a copy of this
statement to the above listed professional for the purposes of compliance with the Health Insurance
Portability and Accountability
Act (HIPAA) .
This field is not part of the form submission.
* indicates a required field