Battle Creek, MI

Dear Applicant:

In order for Battle Creek Transit to evaluate your request for paratransit service eligibility certification, it may be necessary to contact a health care professional for additional information about your disability and the ability to use the regular fixed-route bus service. It is important that you identify a professional who is familiar not only with your disability, but who also understands your ability or inability to travel on the accessible fixed route system.

Health Care Professional information

Name of Professional:

Health Organization:

Address:

City

State:

Zip:

Please check the health care profession of the above-noted individual:

Other (Please Specify):

I authorize my noted health care professional to release to Battle Creek Transit, information about my disability and it’s affect on my ability to travel which may be needed in connection with my request for paratransit eligibility certification. It is my understanding that the information will used solely to determine my eligibility. I understand that I may revoke this authorization at any time.

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Date:

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