Lee County Form

Lee County

Transportation Disadvantaged And/Or Medicaid Transportation Determination Form

Please fill in all items on form completely and accurately.

SECTION I - IDENTIFYING INFORMATION

Medicaid Gold Card Number *

Last Name *

First Name *

Social Security Number *

Telephone Number *

Home Street Address *

Type of Home Address *	House Apartment Nursing Facility ACLF Boarding Home

Apartment Number

County *

City *

Zip Code *

Date of Birth *

Your Current Age *

Your Gender *	Male Female

Total Monthly Income *

Your Race (Optional)	White Black Hispanic Native American Asian Other

SECTION II - NEED DETERMINATION

Have you applied for ADA Transportation with Lee County? *	Yes No

If yes, were you approved or disapproved?	Yes No

Are you eligible for Medicaid Non-Emergency Transportation? *	Yes No

Are you able to operate an automobile, even for short distances? *	Yes No

Do you or anyone in your household own a car? *	Yes No

What are your vehicle license plate(s) number(s)?

What is the total number of persons who reside in your household *

Enter the name of the person who resides with you.

Is this person related to you?	Yes No

Enter this person's Social Security Number

Does this person own a car?	Yes No

If you live in an Assisted Care Living Facility, Nursing Home, ICFMR or Boarding Home, does this facility have a vehicle?	Yes No

Have you ever been transported by the facility?	Yes No

Do you have any family or friends who live in the County you reside in? *	Yes No

Has this person(s) ever transported you to the doctor?	Yes No

Would this person take you to the doctor if you asked them?	Yes No

Do you know someone who would transport you if you paid for the gas? *	Yes No

Have you ever taken the Lee Tran bus to the doctor or to other places? *	Yes No

Can you travel on a Lee Tran bus? *	Yes No

If you cannot travel on a Lee Tran bus, please explain why.

Would you use the Lee Tran bus if you could ride free? *	Yes No

Can you walk without help to the following distances? (Check those that apply)	Across a room One block Two blocks Three blocks One mile

SECTION III - DISABILITY

Are you currently receiving Supplemental Social Security Income (SSI)? *	Yes No

Are you currently receiving Social Security Disability? *	Yes No

Do you consider yourself to be disabled? *	Yes No

If YES, what is the nature of your disability? (Check all that apply)	Blind/Legally Blind Wheelchair User Difficulty Walking Arthritis Cerebral Palsy Multiple Sclerosis Neuromuscular Disease Alzheimers Disease Stroke Epilepsy Respirator or Oxygen Dependent Muscular Dystrophy Mentally Challenged Other

If you chose the disability type "Other" in the previous question, please describe.

Do you require mobility aids? *	Yes No

If YES, which aids do you require? (Check all that apply)	Walker Scooter Guide Dog Cane Personal Care Attendant Wheelchair Other

SECTION IV - FREQUENCY OF USE/DESTINATIONS

What doctors or medical clinics do you visit on a regular basis? *

Download the (PDF) Lee County Form HERE