Healthcare Professional Verification

Healthcare Professional Verification

This individual is applying for ADA Dial-A-Ride service. In compliance with the Americans with Disabilities Act (ADA), Riverside Transit Agency provides ADA Priority Service to persons who, due to a disability, are unable to independently use the public fixed route bus system. RTA fixed route buses are equipped with ramps and lifts therefore eliminating the need to negotiate stairs. Public buses offer additional accessibility features like priority seating for seniors and people with disabilities.

The applicant must have this form completed by a licensed healthcare professional in order to complete the application process. The information you provide will allow us to make an appropriate evaluation to determination eligibility of services and its application to specific trip requests. RTA may contact you if further information is required. Thank you for your cooperation.

Healthcare Professional Information

Please provide the following information:

Applicant/Patient First Name: *

Applicant/Patient Last Name: *

Applicant/Patient D.O.B: * Example: 01/25/1931

Healthcare Professional:

First Name: *

Last Name: *

Email Address:

Address: *

Phone: * Example: 123-456-7890

Professional Title: *

Professional License #: *

Signature: *

By typing your name, you certify the information you are providing is accurate and true. * I accept