Health Care or Service Provider Verification Form

RideKC Freedom in Johnson County – Health Care or Service Provider Verification Form
Applicant Authorization to Release Information

I authorize the licensed professional named below to provide information to RideKC regarding my physical or cognitive ability to use public transportation. This information will be used solely to determine my eligibility for paratransit service.

Applicant Information
- Full Name: First Name* Last Name*
- Date of Birth: Date*
- Phone Number (if known): Area Code Phone Number
Applicant/ Authorized Signature:*

Clear
Date:

MonthDayYear
About RideKC Freedom in Johnson County Paratransit Service

(Please read before completing this form)
RideKC Freedom in Johnson County is a curb-to-curb, shared ride public transportation service for Johnson County residents whose disability or condition prevents them from using regular bus or micro transit services.

Key Features of this Service Include:
- Rides are shared and may include other passengers with different destinations
- Drivers and vehicles vary—and so can travel time and routing
- Pick-up windows are generally 30 minutes, not exact appointment times
- Drivers do not enter buildings or provide personal care assistance
- Riders must be able to navigate the service, recognize their vehicle, and communicate their needs independently or with their own personal assistant
  - Communicate basic needs
  - Identify or respond to their vehicle when it arrives
  - Navigate to/from the curb safely
  - Remain stable and safe during shared, indirect rides
If the rider cannot safely or independently manage these conditions, they may require a Personal Care Attendant (PCA). Your role is to help us understand the functional mobility needs of your client as they relate to using public transportation. This information helps us determine the most appropriate mobility option for them.

Provider Information
1. Your Name

First NameLast Name
2. License/Certification Type:
3. State and License Number:
4. Organization or Practice Name:
5. Phone:
Please enter a valid phone number.
6. Email or Fax:
example@example.com
7. Relationship to applicant:

PhysicianNurseSocial WorkerCase ManagerTherapistOther
If Other, please explain:
Professional Observations

How does this person’s disability or health condition affect their ability to travel safely and independently? (You may include examples related to trip planning, walking distances, navigating public or crowded spaces, effects of changes to schedule, communication methods, etc.):
A: Check any functional challenges that may apply to this individual:

Getting to or from a bus stop (distance, terrain, environment)Standing or waiting for extended periodsNavigating curbs, steps, ramps, or uneven surfacesMaintaining balance or stabilityRecognizing signage or visual informationHearing instructions or alertsRemembering directions, stops, or destinationsManaging stress or behavioral responses while travelingCommunicating clearly with drivers or staffOther Challenges
Please describe:
B. Is their condition expected to stay the same, improve, or change over time?

ImproveStay the sameDeclineNot sure
C. Based on your experience, do you believe this person would benefit from paratransit (curb-to-curb, shared ride service)?

YesNoIt depends
Please explain:
Signature
I certify that the above information is based on my direct knowledge of the applicant’s condition and functional mobility:

Clear
Date

MonthDayYear
Should be Empty:

RideKC Freedom in Johnson County – Health Care or Service Provider Verification Form

About RideKC Freedom in Johnson County Paratransit Service

Provider Information

Professional Observations

Signature