HomeMy WebLinkAbout2022 updated disabled rider formTransit Division Disabled Bus Pass Program
Authorization for Release of Information
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 at any time. 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.
Applicant’s Name _________________________________________ Phone number_____________________
Address__________________________________________________________________________________________
Signature___________________________________________________________________________________________
All questions must be answered to be considered complete
FOR PHYSICIAN USE ONLY :
Please answer the following questions regarding your patient, named above, to enable the City to determine eligi-
bility 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 tempo-
rary, 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 Trans-
portation 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.
Iowa City and University Iowa City and University
Heights Corporate residents only Heights Corporate residents only