QUESTIONS? CALL 455-3330
This application cannot be processed unless it is completed in full.
Part A: This section is to be completed by all applicants.
Part B: This section is to be filled out by a physician or social service
agency if the applicant lives within ¼ mile of a bus route and/or if he/she needs an escort.
Part C: This section only needs to be completed if the applicant receives MEDICAID.
Part D: This section must be signed by all applicants.
Applicants 65 years or older must attach a copy of one of the following forms.
PENNDOT approved age verification:
Armed Forces Discharge Papers
Social Security Statement of Benefits with birthdate
C.Veteran’s Universal Access ID Card
SEND THE COMPLETED APPLICATION TO:
825 West 18th Street
Erie, PA 16502
LIFT Senior Citizen Program
Part A TO BE COMPLETED BY CUSTOMER
PHONE_____________________________DATE OF BIRTH________/________/________
IN CASE OF EMERGENCY CONTACT: _________________________________________
Are you able to use the EMTA bus? _______ Yes ________no
Do you use any of the following equipment: _____cane _____crutches _____walker
______ wheelchair: If yes, can you transfer with minimal assistance? ________
______ Other (please specify)______________________________________________
Please note: Our wheelchair ramps have a loading capacity of 600 lbs, including the wheelchair, and are 28 ½ inches wide by 48 inches long with a door height of 5 feet.
If you live within ¼ mile of a bus route this application MUST be signed in Part B by your physician or a Social Service Agency to qualify for LIFT services.
Part B TO BE COMPLETED BY PHYSICIAN OR SOCIAL SERVICE AGENCY
If the customer cannot use a EMTA bus, please provide a description of the functional disability and the extent of the disability in non-clinical terms:
Is this disability temporary? ________ Does the customer require an escort? ________
I certify that, to the best of my knowledge, the above named person’s functional disability, as stated above, requires paratransit transportation.
Name (Sign)______________________________ (Print) ____________________________
Part C TO BE COMPLETED ONLY BY MEDICAID RECIPIENTS
RECIPIENT #_____________________________CARD ISSUE #______________________
OTHER ELIGIBLE HOUSEHOLD MEMBERS:
You may attach a separate sheet if necessary
Part D TO BE SIGNED BY ALL APPLICANTS
****This application cannot be processed unless signed and dated. If you fail to sign this application it will be returned to you.
Affirmation of Information:
I hereby certify, that, to the best of my knowledge, the information contained herein is true, correct and complete. I agree to report any changes in circumstances immediately to this Service Provider. I understand that documentation of all eligibility factors may be required to determine eligibility correctly or for auditing purposes and that giving knowingly false statements is a criminal offense. I understand that I have a right to request a Department of Public Welfare fair hearing. This affirmation statement covers all attachments required for the determination of eligibility.
Signature of Applicant________________________________________________________
How did you hear about the LIFT? _____Radio ______ TV _______ newspaper ______friend _____other (please specify)_________________________
FOR OFFICE USE ONLY – DO NOT WRITE BELOW THIS LINE
DATE OF SERVICE: _________________________
HEALTH BENEFIT CODE: _______ _______ _______ _______ _______
CATEGORY OF ASSISTANCE: _______ _______ _______ _______ _______
PROGRAM STATUS CODE: _______ _______ _______ _______ _______
MATP FUNDING STATUS: GROUP I __________ GROUP II __________
GROUP II = D-00, D-05, B-00, PD-OO, PD-21, PD-22, PD-29, TB-00, TD-00, TD-11
APPLICATION PROCESSING INFORMATION
AUTHORIZED SIGNATURE: _________________________________________________________________
FUNDING RECEIVED: _________________________________________________________________
The local Area Agency on Aging is requesting the following information to complete State Reporting Requirements. This information is not used to determine eligibility for LIFT services. Providing this information is completely voluntary.
If you are over 65 years of age please check the appropriate boxes below:
Minority Living in Poverty