Phone: (207)

Transcription

1 Regional Transportation Program 127 Saint John Street Portland, ME Phone: (207) Dear Rider: Thank you for choosing Regional Transportation Program for your mobility needs. Our goal is to provide you with safe, reliable and friendly transportation. RTP asks all riders to complete a Transportation Necessity & Release of Information Form and/or a Transportation Application to allow RTP to plan rides that best fit our riders needs. This information may also be used to determine a rider s qualification for funding by one or more of our partner agencies. Providing documentation to verifiy income for all income sources is an essential part of the application process to accurately determine your funding qualification. Riders who access RTP S services through MAINECARE or DHHS are required to complete this application and return it prior to receiving transportation. Please complete the Transportation Application & the Transportation Necessity & Release of Information forms and return them to RTP. If you have any questions or require assistance to complete your application, please contact our office at x 1. Upon receipt of your completed forms, RTP will assess and notify you of your eligibility for funding when this process is complete. Thanks for riding with RTP! Sincerely, RTP Intake Team Flip this letter over for IMPORTANT TIPS to make all your RTP rides GREAT RIDES! Regional Transportation Program 127 Saint John Street Portland, ME PHONE: (207) FAX (207)

2 RTP is a shared-ride mobility service. We serve hundreds of people throughout Cumberland County daily, and provide over 1,200 rides per day in the region and beyond. Here are some IMPORTANT TIPS to HELP MAKE YOUR RIDE with RTP A GREAT RIDE BOOK TRIPS EARLY. Reservations can be made up to 2 weeks in advance. All requests (except ADAPT) must be received AT LEAST 48 hours in advance. BE READY WHEN THE DRIVER ARRIVES. RTP Drivers follow a 5-Minute Wait Rule. Please be considerate of others and understand that being late for your ride impacts all rides after you. PLAN TRIPS WITH A 1-hour PICK-UP WINDOW in mind. RTP schedules all trips with a 1 hour pick-up window. That means your driver may arrive up to 30 minutes BEFORE and as much as 30 minutes AFTER your scheduled pick-up time. COMMUNICATE ANY CHANGES YOU HAVE. Inform RTP of changes in mobility needs, changes of address, phone number, caregiver information, etc. Accurate, updated rider information is essential for RTP to provide the safest and most excellent service. TALK TO US FIRST IF YOU PLAN TO HAVE SOMEONE ELSE RIDE WITH YOU. We have a limited number of seats and schedule trips carefully. For everyone s comfort and safety, we don t allow extra riders without prior clearance from a member of the Mobility Team. TAKE CARE OF ANY PERSONAL ITEMS YOU BRING WITH YOU. Riders are responsible for any items brought onto a vehicle. If you accidentally leave something behind, you can retrieve it from the RTP office at 127 St. John Street in Portland. BE FLEXIBLE. We are not able to accommodate every trip request, but our Mobility Team does its best to meet a high demand for rides. If we can t find a seat for you on a specific date or at a specific time, we might ask if you are able to reschedule an appointment or take your trip a different day. We want to help you get where you need to go, and sometimes we need your help to make that happen. RTP s provides GREAT RIDES for EVERYONE. VISIT US ONLINE or CALL US!

3 Regional Transportation Program Application for Transportation Services The State of Maine, DHHS requires riders to fill out an application to receive transportation service funding under their contract. This application must be filled out correctly and returned to RTP before transportation is arranged. Last Name First Name MI Social Security # - - Date of Birth / / Spoken Language Home Address City, ME ZIP Primary Tel # - - Alt Tel # - - Mailing Address, if different Do you receive MaineCare? if yes, number Please identify any assistive devices you require such as wheelchair, walker, cane or oxygen. Income and Source Please check and fill out all that apply for all household members. The information requested below is needed to determine your eligibility for service. Incomplete applications will be returned. Please see reverse page for income verification requirements. Copies of income verification must be attached to this application upon return to RTP. [ ] TANF Amt $ month [ ] Dividends / Interest Amt $ month [ ] SSI Amt $ month [ ] Unemployment Comp Amt $ month [ ] Social Security Amt $ month [ ] Rental Income Amt $ month [ ] Veterans Pension Amt $ month [ ] Retirement Pension Amt $ month [ ] General Assistance Amt $ month [ ] Child Support Amt $ month [ ] Employment Wages Amt $ month [ ] Other (specify) Amt $ month (gross wages) Total Monthly Income Number of people in household I certify under penalty of perjury that to the best of my knowledge the above information is correct. If there is any change in my income or living arrangement, I will notify the agency which is providing me service at once. I understand this information will be provided to the central office of the Department of Human Services for use in administration of this program. SIGNATURE DATE Important Information on Reverse Side

4 Income verification (attached documentation to application) Wages 4 current and consecutive pay stubs Additional Information Unemployment Compensation One month s worth of pays stubs TANF, SSI, Social Security, Veterans Pension, General Assistance, Dividends/Interest, Rental Inocme, Retirement Pension, Child Support / Alimony, Other Income Copy of check(s), check stub(s), or bank statement showing direct deposit. One month s worth of verification required. PLEASE MAIL THIS APPLICATION ALONG WITH THE NECESSARY INCOME VERIFICATION TO: Regional Transportation Program 127 Saint John Street Portland, ME Or you can bring it into our office at 127 St. John St, Portland Monday through Friday 8:00am to 4:00pm HEARING RIGHTS If you are not satisfied with a decision made regarding your eligibility for the provision of social services, you have the right to ask for a hearing before the commissioner of the Department of Human Services or his agent. If you want an informal conference with the Regional Director or the Provider Agency or his agent, you should request it within ten (10) days of the notice of the action by contacting the office where you made application for or received the service. If you want a formal hearing, you must request it by contacting the same office or the Commissioner of the Department of Human Services, State House Station #11, Augusta, Maine A request for a formal hearing must be made within thirty (30) days of the effective date of the notice of the action you wish to appeal. If you request either type of hearing within (10) days of the date of the notice regarding your eligibility for or the provision of social services, the proposed action will not go into effect until your appeal has been heard and a decision rendered. CIVIL RIGHTS NOTICE If you feel you have been discriminated against because of your race, color or national origin, you may file a complaint requesting a hearing on this matter with a Regional or the State Office of the Department of Human Services or with the U.S. Department of Health, Education and Welfare, Washington D.C. REPORTING RESPONSIBILITIES REMEMBER! It is your responsibility to report to the agency providing the social service to you all changes in your circumstances which could affect your eligibility for the services. Should you receive benefits to which you are not entitled due to failure to report changes promptly and correctly, you will be expected to repay any benefits for which you were not eligible. FRAUDULENT REPRESENTATION The willing acceptance and/or use of any State and/or Federal funds under this program for which a person knowingly is not eligible may constitute fraud and subject the user to prosecution under penalties of law.

5 Regional Transportation Program Transportation Necessity and Release of Information Date Head of Household Name: Address Phone Number City, State, Zip SSN MaineCare No DOB Additional Family Members who may require transportation services (Please Print) Name Social Security Number MaineCare Number Date of Birth Please read, sign below, and return to RTP as soon as possible. Regulations require that we have this signed release on file in order to provide you and/or your family members with transportation services. I understand this is an authorization for release of information and is confidential and will only be used for verification, scheduling, and transportation purposes between RTP staff, MaineCare and DHHS staff, and the facilities that I or my family members utilize. Notice to Agency/Person receiving this information: Under provisions of Title 42 of the Code of Federal Regulations, you may not re-disclose any of this information to another Agency/Person without specific written consent. Signed: Date: Additional Signature Required for MaineCare Recipients I,, certify under penalty of perjury that I and/or my family members listed on this form have no means of transportation other than RTP s services, or would be unable to provide my own and/or family member transportation without reimbursement. If there is any change in MaineCare eligibility or any changes in appointments I will notify RTP at once. Signed: Date: I have read and understand RTP s Cancellation Policy and Trip Skip Rules Signed: Date:

6 IMPORTANT INFORMATION PLEASE READ! Important information for all Department of Human Services clients regarding social services provided directly by the Department or through public or private community agencies which provide services under contract to the Department of Human Services. HEARING RIGHTS If you are not satisfied with a decision made regarding your eligibility for or the provision of social services, you have the right to ask for a hearing before the Commissioner of the Department of Human Services or his/her agent. If you want an informal conference with the Regional Director or Director of the provider agency or his agent you should request it within ten (10) days of the notice of action by contacting the office where you made the application for or received the service. If you want a formal hearing, you must request it by contacting the same office or the commissioner of the Department of Human Services, State House, Augusta, Maine A request for a formal hearing must be made within thirty (30) days of the effective date of the notice of the action you wish to appeal. If you request either type of hearing within ten (10) days of the date of the notice regarding your eligibility for or the provision of social services, the proposed action will not go into effect until your appeal has been heard and a decision rendered. CIVIL RIGHTS NOTICE If you feel you have been discriminated against because of your race, color, or national origin, you may file a complaint requesting a hearing on this matter with the Regional or the State Office of the Department of Health, Education, and Welfare, Washington, D.C. REPORTING RESPONSIBILITIES REMEMBER! It is your responsibility to report to the agency providing the social service to you all changes in your circumstances, which could affect your eligibility for the services. Should you receive benefits to which you are not entitled due to failure to report changes promptly and correctly, you will be expected to repay any benefits for which you are not eligible. FRAUDULENT REPRESENTATION The willing acceptance and/or use of any State or Federal funds under this program for which a person knowingly is not eligible may constitute fraud and subject the user to prosecution under penalty of law. For further information about any of the above, call or write to RTP.

7 RIDER s COPY Yours to Keep RTP S CANCELLATION POLICY and NO-SHOW RULES When Riders no-show or cancel Reserved Trips at the last minute, it creates problems for RTP and impacts other Riders. Skipped trips and late cancellations make it hard for RTP s to provide the efficient, high quality service so many people depend on to get where they need to go. RTP encourage Riders to keep their reservations and requires that changes or cancellations be made in advance. We know things happen, and sometimes rides must be cancelled. RTP expects everyone to follow the rules for cancelling or changing reservations in order to avoid Ride Privilege Restrictions resulting from multiple No-Shows. What are the Rider s Responsibilities when cancelling or changing Trip Reservations? The Rider (or a person acting on a Rider s behalf) MUST: Contact RTP at least 2 hours in advance of the scheduled pick-up time. If changing or cancelling a reservation after regular office hours, call RTP and use the Afterhours Cancellation message box. Leave Rider s name, the date and time of the Trip Reservation being changed, and a contact name and number so RTP can follow-up. Call in changes NO LATER THAN 5:00 p.m. the day before the scheduled trip for Trip Reservations with a pick-up time scheduled earlier than 9:30 a.m. MISSING A RESERVED TRIP WITHOUT GIVING THE REQUIRED NOTICE IS A NO SHOW What happens when a Rider gets charged with a No-Show? Every No-Show is recorded. Having 3 or more No-Shows in a 30 day period will result in the following: 1 st Violation: The Rider (or someone acting on the Rider s behalf) will need to call RTP to make Trip Reservations 2 business days prior to the date a trip is needed for all trips. Subscription trip services for on-going rides will be suspended and all reservations will need to be made 2 business days in advance for a period of 30 days following the violation. 2 nd Violation: If a Rider has a second occurrence of 3 no-shows in a 30 day period within 12 months of the 1 st Violation, ride privileges with RTP may be restricted for a period of 30 days. If the Rider is a MaineCare member, the Friends and Family option will still be available. If No-Show limits are exceeded after the 2 nd Violation, RTP may increase the Ride Privilege Restriction period. How does a Rider appeal a Ride Privilege Restriction? To appeal a Ride Privilege Restriction, contact the Mobility Operations Manager at RTP to explain why you believe the restriction is wrongly charged. RTP staff will review trip information and communicate a decision within 3 business days of receiving notice of the appeal. An appeal can be made by phone: ext. 122, or by mail: RTP, 127 St. John St. Portland, ME It is EASY to avoid Ride Privilege Restrictions. Just call AT LEAST 2 hours BEFORE the scheduled pick-up time for your Reserved Trip if you need to cancel or change your reservation. The earlier the better! If you need help understanding any Rider Responsibilities, please call RTP for assistance. We are here to help. Thank you for following these simple rules and helping RTP make every ride a GREAT RIDE!