Access Services

Applying for Access> Applying for Access> In-person Evaluation Required> Submitting The Application> Other Transportation Resources

Applying for Access

Access provides free transportation toand from your in-person evaluation.
An in-person evaluation is required toApplicants also have the option todetermine your eligibility with Access
Services. In order to ensure that Access has provide their own transportation.
the necessary information to process yourRequired In-person Evaluation
application, complete the following steps:> A photo will be taken. We will ask toremove articles that obscure your face.
Access Rider ID number is required.
> If applicable, bring your primary
If you do not have an Access ID Number,
mobility device that you intend toplease contact Customer Service
use while out in the community.
at 1.800.827.0829 (TDD 1.800.827.1359)> If you need assistance, please bring aor visit eligibility.accessla.org to have one
personal care assistant (PCA).
issued (application will not be processed> Bring a valid photo ID. Access
if ID number is missing).
accepts the following form(s) of1 Complete and mail the application
photo ID (required):a. State issued Driver’s License or ID
portion in the enclosed envelope to:b. Military ID
Access Eligibility Centerc. U.S. Passport
5747 Rickenbacker Rd
d. LACTOA Reduced Fare ID card
Commerce, CA 90040 or via email
e. Other transit operator reduced
to: EligDept@accessla.org
fare ID card
If you have other questions related
to the application or need assistance, > Children under 18 years of age:a. School ID
filling out the form, please callb. Birth Certificate with parent’s
1.800.827.0829 (TDD 1.800.827.1359).
photo ID
2 Allow seven (7) calendar days
> Bring any documentation thatwill support the information inafter you send in your application
your application (optional).
form to call the Access Eligibility> Eligibility is based on your functional
Scheduling Center.
abilities to use fixed route bus or
3 Schedule your in-person evaluation attrain services.
> The evaluation will include an626.532.1616 (TDD 626.532.1620),
interview as well as a functional and/Monday through Friday fromor a cognitive evaluation, if necessary.
8am-5pm. Please do not call before
The Evaluator will be looking at yourthe seven (7) calendar day period.

functional skills which are needed
to ride buses and trains.
> If the Evaluator needs verificationfrom your healthcare professional,
they will contact them.
The application process will beconsidered complete with the following:a. Completed application including
a copy of your photo ID
b. Completed in-person evaluationc. Completed healthcare professionalverification (if applicable)
You will receive a letter within 21 days
after the completion of the application
process informing you of youreligibility status.
This application is available in alternativeformats. If you require an accessible
format of this application, pleasecontact Access Customer Service:
1.800.827.0829 (TDD 1.800.827.1359)
between the hours of 8am and 5pm
Monday through Friday.
If you have a concern about what
information you need or what to do toprepare, the Disability Rights Education
and Defense Fund (DREDF) has
published “ADA Paratransit Eligibility:
How To Make Your Case.” You can geta copy of this helpful guide online atdredf.org or by calling Access Customer
Service Center at 1.800.827.0829(TDD 1.800.827.1359).

Other Transportation Resources

Los Angeles County has fixed routebus and train services that are equippedwith ADA accessible features suchas lifts or ramps, securement spaces,
designated priority seating, stopannouncements, audio announcements,
handrails, lighting, and operators
who are trained to assist passengers
with disabilities. These modes oftransportation do not requireprior reservation.
For more information about bus andtrain routes, schedules, and/or reduced
fares in Los Angeles County, please
visit metro.net or call 323.GO.METRO(323.466.3876). Riders with hearingor speech impairments can use theCalifornia Relay Service. Dial 711 andthe number you need.
Access can assist with your search fortransportation options including Travel
Training which provides assistance withlearning how to use the fixed route bus
or train services. For more information
call Access Customer Service at
1.800.827.0829 (TDD 1.800.827.1359)
or visit accessla.org.

Questions? Please callCustomer Service:
1.800.827.0829(TDD 1.800.827.1359)

In-person Evaluation Application
1

Personal Information
Access ID number (6 or 7-digit number)*Application will not be processed without ID#.

Access ID number required:
To request an ID number, please call
Customer Service at 1.800.827.0829
or visit eligibility.accessla.org.

Last nameFirst name		MI

Medi-Cal ID number (optional):

I do not have aMedi-Cal number

Applicant’s primary language (if other than English)
Date of birth

Gender:

MaleHome street address
CityFemale

Non-binary

Apt number
State

Zip

Mailing address (if different from your home address)

Apt number

CityStateZip

Primary phone number

Alternate phone number

Cell

TDD

Cell

TDD

EmailAccess Services accessla.org

12

3

Emergency ContactName

Relationship to applicant

Primary phone numberAlternate phone number

Current Use of Public Transportation
When was the last time you rode the fixed route bus or train independently?
How frequently do you ride the fixed route bus or train?
Daily
WeeklyMonthly
Not currently using

Never used

What is the farthest that you can travel outdoors without the help of anotherperson (using mobility device/aid, if applicable)?
Less than 1 block
1-4 blocks
More than 4 blocks
How far do you live from your nearest bus stop?
Less than 1 block
1-4 blocks
More than 4 blocks

Do not know

When using fixed route bus or train do you travel?
Independently
With assistanceNot applicable
Are there any physical barriers or environmental conditions that prevent you
Yes
Nofrom using public transportation?

Access ID number
2

Disability/Health Condition Information
4Disability / Health Condition Information
Please describe the disability or health condition which prevents your ability
to travel on a bus or train independently. You may attach more documentation
on a separate page.

Is this a permanent disability or health condition?
Yes
No
If no, how long do you expect it to prevent you from using fixed route buses
Week(s)Month(s)or trains?

5Mobility Devices / Aids
Do you require assistance when traveling on the bus or train?
Sometimes
Not applicable

Yes

NoYes
No
Do you use a service animal?
What function is it trained to perform?
What is your primary mobility device/aid? (If applicable)
Powered wheelchair
Manual wheelchair
WalkerCane
Brace
Prosthesis
Crutches
Powered scooter

White cane
Portable oxygen

Other:

Access ID number3

Mobility Devices / Aids (cont.)
What is your secondary mobility device/aid? (If applicable)
Powered wheelchair
Manual wheelchair
WalkerCane
Brace
Prosthesis
Crutches
Powered scooterWhite cane
Portable oxygen

Other:
You will be assessed with the primary mobility device/aid that you bring to theeligibility center at the time of your appointment. If you change your mobility
device following your evaluation, you may be required to return for a newevaluation in your new device. Use of a different mobility device may change
your functional ability to use accessible fixed route transit.
IMPORTANT: Most of the accessible vehicles in our fleet are designed toaccommodate a mobility device no larger than 30 inches wide by 48 inches
long and/or weighing with its passenger up to 600 pounds. While we makeall reasonable efforts to accommodate our riders, if your mobility device islarger than this, we may be unable to transport you either because it would
damage the vehicle or to do so would impose an unreasonable safety hazard.
6Healthcare Professional Contact Information
Please provide the contact information of your treating healthcare professional
who is familiar with your condition and, if needed, could be contacted forclarifying information.
The following licensed healthcare professionals are authorized to provide
clarifying information:> Registered nurse> Psychologist> Physician (MD or DO)> Psychiatrist> Ophthalmologist> Optometrist> Physical therapist> Occupational therapist> Other licensed provider familiar with your condition
Access ID number
4

Healthcare Professional Contact Information (cont.)

Healthcare professional’s nameSpecialization

Institution/facility/agency nameStreet address

7

Suite number

City

State

Primary phone number

Alternate phone number

Fax number

EmailZip

Certification and Authorization for Release of Information
I hereby certify that, to the best of my knowledge, the information given in thisapplication is correct. I authorize my healthcare professional to release any andall information about my disability or health condition and its effects on myfunctional ability to travel. I understand that all medical information will be kept
strictly confidential. I agree to undergo an in person assessment of my functional
abilities and limitations for the purpose of making a determination regarding myeligibility for ADA paratransit service.

Print nameSignature

Date

Access ID number5

8

Person That is Authorized to Complete This Form on Behalfof the Applicant (optional)

Name

Relationship to applicant

Primary phone numberAlternate phone number

Referring agency (if applicable)
Signature of person, other than applicant, completing form

Date

Access ID number6

Your Access
Application is here.

20-0362 ©2020 Access Services

Access Eligibility Center
5747 Rickenbacker Rd
Commerce, CA 90040