Check Form Regional Transportation District In order to prevent delays in your patient's application, please follow these instructions: Complete the Medical Verification Form in your web browser. Save a copy of this form on your computer. To do this, choose File – Print – Save as PDF in the destination field and select the location to save the document. Print the Access-a-Ride Professional Medical Verification Form. Sign the Medical Verification Form. Fax the completed form (2 pages) to 303-299-2169 OR return the printed form to your patient Health care providers who can complete this form (must be treating the disability for which applicant is applying for paratransit service): Physician PT / OT Registered Nurse Psychiatrist Social Worker (MSW) PA / NP Respiratory Therapist Mental Health Clinician Psychologist Optometrist Rehabilitation Counselor Ophthalmologist Chiropractor Orientation & Mobility Specialist To be completed by the medical provider of AAR Applicant Name/Credential of Professional: License Number of Professional: Phone Number: Name of applicant: How long has this applicant been under your care? Most recent visit date: Does the applicant’s disability prevent the applicant from getting to / from and riding the bus / light rail system? Yes Sometimes No If yes or sometimes, please explain how the applicant’s disability or health related conditions prevent use of the public bus / light rail system: Does this applicant need someone to accompany him/her at all times? Yes No Does the applicant have the mental capacity, visual and/or hearing ability to: Ask for, understand and follow directions? Ask for, understand and follow directions? Yes No Ask for assistance from appropriate sources? Ask for assistance from appropriate sources? Yes No Safely cross a major street? Safely cross a major street? Yes No Safely travel through crowded or complex facilities? Safely travel through crowded/complex facilities? Yes No Recognize a destination or landmark? Recognize a destination or landmark? Yes No Signal a bus operator to get off at destination stop? Signal a bus operator to get off at destination stop? Yes No Filter environmental noise? Filter environmental noise? Yes No Judge traffic flow? Judge traffic flow? Yes No Regarding vision impairments only: Is the applicant able to locate steps or curbs? Is the applicant able to locate steps or curbs? Yes No Is the applicant impacted by bright sunlight? Is the applicant impacted by bright sunlight? Yes No Is the applicant limited by dimly lit conditions? Is the applicant limited by dimly lit conditions? Yes No Is the applicant’s vision impacted at night? Is the applicant’s vision impacted at night? Yes No Is the applicant, while using their mobility aid, able to independently: Travel outdoors on their property? Travel outdoors on their property? Yes No Travel up to 1 block? Travel up to 1 block? Yes No Travel up to 3 blocks? Travel up to 3 blocks? Yes No Stand for up to 15 minutes with support? Stand for up to 15 minutes with support? Yes No Stand for up to 15 minutes without support? Stand for up to 15 minutes without support? Yes No Travel up or down hills? Travel up or down hills? Yes No These impairments are: Stable Progressive Degenerative Temporary, duration: If temporary, what is the duration Does weather impact the applicant’s ability to travel? Windy Weather Windy Weather Yes No Cold weather Cold weather < 30 °F < 40 °F < 50 °F No Hot weather Hot weather > 70 °F > 80 °F > 90 °F No Signature of Provider Date *** MEDICAL VERIFICATION FORMS LACKING A SIGNATURE AND LICENSE NUMBER MAY NOT BE PROCESSED *** Please return this form to the applicant, or fax to 303-299-2169, once completed.