Patient First NameMIPatient Last NameDOBPhysician InformationPhysician First NamePhysician Last NameTitle DO MD etcName of PracticeMedical License NoStreet AddressCityZIP CodeDate of applicant146sla ID: 892137
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1 Medical Verification FormThis form shall
Medical Verification FormThis form shall be completed by a physician licensed to diagnose your condition or disability and is able to provide the needed information that would help determineeligibility for ADA paratransit service. Incomplete forms will be returned. Patient First Name: MI: Patient Last Name: D.O.B. / / Physician Information Physician First Name: Physician Last Name: Title (DO, MD, etc.): Name of Practice: Medical License No.: Street Address: City: ZIP Code: Date of applicant’slastvisit: Medical diagnosis of disability/condition: Please describe PhysicianSignatureDate The original Medical Verification Form must be received within 30 days of the ADA Paratransit Application. Applications will only be considered completed