HomeMy WebLinkAboutDisabled bus pass 2015
Transit Division Disabled Bus Pass Program
I authorize my physician, ______________________________________________________, to release information
to the City of Iowa City regarding my disability which may qualify me to receive a bus pass entitling me to ride Iowa
City Transit for free during off-peak hours. I understand that the City of Iowa City will keep this information
confidential and that it will only be used to determine my eligibility for an Iowa City Transit disability pass.
Authorization for Release of Information
Applicant’s Name_____________________________________________________________ Phone Number_________________
Address_______________________________________________________________________________________
Signature______________________________________________________________________________________
FOR PHYSICIAN USE ONLY:
Please answer the following questions regarding your patient, named above, to enable the City to determine eligibility for a
Transit pass.
Disability means, with respect to an individual, a physical or mental impairment that substantially limits
one or more of the major life activities of such individual.
1. According to this definition, is your patient disabled?
Yes_______ No_________
2. If you answered yes, is the disability permanent or temporary? Permanent_________ Temporary_______ If temporary,
what is the expected duration of the disability? ______________________
Physician’s name_________________________________________________ Phone number_____________________
Physician’s address___________________________________________________________________________________
Physician’s signature______________________________________________ Date______________________________
Office stamp here or attach business card:
If you have any questions regarding this form, please call 319-356-5151 option 2. Please mail or deliver form to Transportation
Services 335 E Iowa Avenue Iowa City, IA 52240.
Physician’s statement must be filled out and professional verification attached to be considered a complete form.
__________________________________________________All questions must be answered to be considered complete____________________________________________________________________
Iowa City and University
Heights Corporate residents only
Iowa City and University Heights
Corporate residents only