Lrelated medical information to MCTS. I ul(**/**)

MUST BE COMPLETED BY TREATING PHYSICIAN OR LICENSED HEALTH CARE PROVIDER (WI MEDICAL LICENSE) To qualify for an MCTS Reduced Fare Card, your patient(listed on reverse side) must have a disability that falls within the eligibility criteria listed below. Certain conditions do not qualify, i.e., pregnancy, obesity, drug/alcohol addiction, controlled epilepsy. Please check all that apply. Is the impairment permanent? Yes No If no, duration of impairment

Applicant’s impairment DOES NOT MEET any of the functional limitations listed above. Therefore, I cannot certify that the applicant’s impairment meets the eligibility criteria for receiving an MCTS Reduced Fare Card. Please Print: All information in this box MUST be provided by treating physician or licensed health care provider (WI Med Lic). Physician’s / Health Care Provider’s Name State License Number (Required) Office Address City State Zip Code

Area Code + Phone Number Area Code + Fax Number

I certify that the applicant (listed on reverse side) has a disability as defined by the above criteria, and that the information I have provided is true and correct. The applicant is currently under my care for the disabilities listed above. Authorized Signature Date

A. Non-Ambulatory:

1. I mpairment which requires individual to use a wheelchair or similar mobility device.

B. Semi-Ambulatory:

1. A rthritis - American Rheumatism Assoc. may be used as a guideline for the determination of disability; Therapeutic Grade III, Functional Class III, Anatomical State III, or worse is evidence of arthritic disability.

2. L oss of Extremities - Anatomical deformity of or amputation of hand(s) and/or feet, or loss of major function.

3. C erebrovascular Accident - Ongoing debilitating effects following occurrence of CVA, or effects of Cerebral Palsy.

4. C ardio-pulmonary - Serious loss of heart or lung reserves as shown by X-ray, EKG or other tests and in spite of medical treatment, there is breathlessness, pain or fatigue.

5. D ialysis - Individual who must use a kidney dialysis machine to sustain life.

6. Other

(Diagnosis)

How does this affect mobility?

C. Visual Impairment:

1. L egally Blind - Visual impairment that is bilateral and not correctable with lenses.

2. C ontraction of Visual Field - Persons whose widest diameter of visual field subtends an angular distance of 20 degrees, or less than 10 degrees from point of fixation, or whose visual field efficiency is 20 degrees or less.

D. Hearing Impairment:

1. L egally Deaf - Hearing impairment that is bilateral and not correctable by hearing aid.

E. Cognitive Impairment:

1. D evelopmentally Disabled - Cognitive disability that originates before 18.

2. Adult Intellectual Disability

3. A utism - Monotonously repetitive motor behavior with severe withdrawal, inappropriate response to stimuli, or very inadequate social relationships.

4. Schizophrenia

5. O rganic Brain Syndrome/Bi-Polar - Cognitive

disturbances that require boarding or home care, funded work activity or workshop.

F. Neurological Disabilities:

1. C erebral Palsy - Impairment not controlled with medication.

2. M ultiple Sclerosis - Impairment not controlled with medication.

3. E pilepsy - Grand Mal or Psychomotor; Persons who are seizure- free for period of six months do not qualify.

G. Other Disability:

(Diagnosis)

How does this impact ability to use transit?

Contact this candidate