Access Services

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

Applying for Access

Required In-person Evaluation

An in-person evaluation is required to> If applicable, bring your primary
determine your eligibility with Accessmobility device that you intend toServices. In order to ensure that Access has
use while out in the community.
the necessary information to process your > If you need assistance, please bring aapplication, complete the following steps:
personal care assistant (PCA).
> Bring a valid photo ID. Access accepts
Access Rider ID number is required.
the following form(s) of photo ID:
If you do not have an Access ID Number,a. State issued Driver’s License or ID
please contact Customer Serviceb. Military ID
at 1.800.827.0829 or visitc. U.S. Passport
eligibility.accessla.org/scheduler tod. LACTOA Reduced Fare ID card
have one issued (application will note. Other transit operator reduced
be processed if ID number is missing).
fare ID card
> Bring any documentation that
1 Complete and submit the application
will support the information inportion in the enclosed envelope to:your application.
Access Eligibility Center> Eligibility is based on your functional
5747 Rickenbacker Rd
abilities to use fixed route bus orCommerce, CA 90040
train services.
2 Allow seven (7) calendar days
> The evaluation will include an interview
after you send in your application
as well as a functional and/or aform to call the Access Eligibility
cognitive evaluation, if necessary.
Scheduling Center.
The Evaluator will be looking at your3 Schedule your in-person evaluation atfunctional skills which are needed
626.532.1616 (TDD 626.532.1620),
to ride buses and trains.
Monday through Friday from> If the Evaluator needs verification
8am-5pm. Please do not call before
from your healthcare professional,
the seven (7) calendar day period.
they will contact them.
Access provides free transportation to andfrom your in-person evaluation. Applicantsalso have the option to provide their owntransportation.

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 alternative
formats. 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 (TDD1.800.827.1359).

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 call
Customer 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)

Access ID number required:
To request ID number, pleasecall Customer Service or visit
eligibility.accessla.org/scheduler

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:

Male

Home street address
CityFemale

Non-binary

Apt number
StateZip

Mailing address (if different from your home address)

Apt numberCityStateZip

Primary phone number

Alternate phone numberCellTDD

Cell

TDD

EmailAccess Services accessla.org

1

2

3

Emergency Contact

Name

Relationship to applicant

Primary phone number

Alternate phone number

Current Use of Public Transportation
When was the last time you rode the fixed route bus or train?
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 block1-4 blocks
More than 4 blocks
When using fixed route bus or train do you travel?
Independently
With assistanceNot applicable
4

Disability / 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.

Access ID number2

Disability/Health Condition Information
Disability / Health Condition Information (cont.)
Is this a temporary disability or health condition?
YesNo
If yes, how long do you expect it to prevent you from using fixed route buses
Week(s)Month(s)or trains?
Are you currently receiving any treatment?
YesNo
If yes, please provide information on what type of treatment you are
currently receiving:

5Mobility Devices / Aids
Do you require assistance when traveling on the bus or train? (a personal
Yes
NoSometimes
Not applicablecare assistant)?
YesNo
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
Walker
CaneBrace
Prosthesis
Crutches
Communication board

Powered scooter
White cane
Portable oxygenOther:

Access ID number3

Mobility Devices / Aids (cont.)
What is your secondary mobility device/aid? (If applicable)
Powered wheelchair
Manual wheelchair
Walker
CaneBrace
Prosthesis
Crutches
Communication board

Powered scooter
White 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:> Physician (MD or DO)> Registered nurse> Psychologist> 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 numberCityStateZip

Primary phone number

Alternate phone number

Fax number

EmailCertification 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
and all information about my disability or health condition and its effects on
my functional ability to travel. I understand that all medical information will bekept strictly confidential. I agree to undergo an in person assessment of myfunctional abilities and limitations for the purpose of making a determination
regarding my eligibility for ADA paratransit service.

Print nameSignature

Date

Access ID number
58Person, Other Than Applicant, Completing Form (optional)

Name

Relationship to applicant

Primary phone number

Alternate phone number

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

Date

Access ID number
6xx%

0000000

Your Access Services
information is here.

19-0059 ©2018 Access Services

Access Eligibility Center
5747 Rickenbacker Rd
Commerce, CA 90040