AAR Medical Provider Form

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):

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

Yes No

These impairments are:

Stable Progressive Degenerative Temporary

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.