MEDICAL ASSISTANCE TRANSPORTATION PROGRAM ELIGIBILITY FORM

MEDICAL ASSISTANCE TRANSPORTATION PROGRAM ELIGIBILITY FORM
SECTION 1 - GENERAL INFORMATION
Rider Name*

FIRST NAMELAST NAME
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number: *
Format: (000) 000-0000.
Social Security Number
This field is optional if you wish not to apply it a staff member will follow up with a phone call for this information
BIRTHDATE*

MonthDayYear
Date
Email Address
example@example.com
REQUIRED TO PROVIDE COPY OF: PROOF OF AGE ID *

Cancelof
COPY OF ACCESS CARD

Cancelof
I will be riding on Pike County Transportation VehiclesI will use my own vehicle or that of another and would like to apply for Mileage Reimbursement
SECTION 2- AFFIRMATION OF INFORMATION
Please note that all children ages 0-8 years old must be in an appropriate child safety seat. Pike County Transportation does not provide child safety seats. Transportation will be denied if you do not have the appropriate seat.

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 (PCT I understand that documentation of all eligibility factors may be required to determine eligibility correctly or for auditing services 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. The above statement covers all attachments required for the determination of eligibility.
Applicant or Designee signature*

Clear
Date*

MonthDayYear
Date
SECTION 3 - ADDITIONAL INFORMATION
YesNo
SPECIFY TYPE*
YesNo
YesNo
YesNo
REASON FOR ESCORT*
PLEASE SPECIFY ANY OTHER SPECIAL NEEDS

EMERGENCY CONTACTS

Rows	NAME	PHONE NUMBER	Satisfied
1
2
3
4

DIRECTIONS TO YOUR HOME MUST INCLUDE WHICH SIDE OF THE STREET COLOR OF HOUSE AND LANDMARKS
Pike County Transportation provides rides in the least costly way to meet your travel needs. Please be aware that the information you have provided on pages 1 thru 2 will be used to determine the most cost effective and most appropriate mode of transportation. If you do not agree with the determination of mode, you do have the right to appeal. Information on how to appeal the mode is given in our Consumer Welcome Brochure.

Please make sure all sections on the application are completely filled out or this could delay the registration process.
After reading the following statement, please sign and date below. I have reviewed pages 1 thru 2 and the information given is true and correct. I understand that this information will be used to determine the mode of transportation, PCT will assign to me. I will notify PCT of any changes that occur that could affect the type of transportation provided.Please make sure all sections on the application are completely filled out or this could delay the registration process. *

Clear
Date

MonthDayYear
Date
Should be Empty:

MEDICAL ASSISTANCE TRANSPORTATION PROGRAM ELIGIBILITY FORM

SECTION 1 - GENERAL INFORMATION

SECTION 2- AFFIRMATION OF INFORMATION

SECTION 3 - ADDITIONAL INFORMATION