Administration of ADA Paratransit Eligibility Appeal Programs (2018)

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F-1 A P P E N D I X F Capital Metro Paratransit Eligibility Appeal Determination Form Determination Form HB 695800 MetroAccess Paratransit Eligibility Appeal Determination Form Client Name: Client ID: Date of Appeal: Initial determination: On ____________ (Date) an ADA paratransit eligibility appeal was conducted on behalf of ______. After careful review and consideration of all evidence presented during the hearing, the Appeals Panel makes the following determination: __A. The Appeals Panel concurs with the initial eligibility decision and recommends upholding the previous eligibility determination __B. The Appeals Panel does not concur with the initial eligibility decision and has made the following determination: Justification for Panel Decision (select one) __A. The panel concurs with the initial eligibility determination based on information gathered during the functional assessment, initial application, and any additional follow-up __B. The panel does not concur with the initial eligibility determination. Additional information provided during the appeal was not addressed in the eligibility review and/or the functional assessment recommendation completed by a skilled clinician. Please specify why new information about the applicant’s functional abilities is not consistent with initial determination. Refer to Attachment 1 for an explanation of individual panel member review comments. Respectfully submitted, Appeal Panelist (PRINT NAME) Signature Date Appeal Panelist (PRINT NAME) Signature Date Appeal Panelist (PRINT NAME) Signature Date

F-2 Administration of ADA Paratransit Eligibility Appeal Programs Determination Form HB 695800 Attachment 1 Documentation of Individual Panel Member Review Comments The MetroAccess paratransit appeals panel consists of a three member panel including a member of the Access Advisory Committee, Community Representative and Capital Metro representative. The following is a summary of the individual panel member’s review of this appeal. Access Advisory Member This MetroAccess appeals panelist recommends the following: __A. Concurs with the initial eligibility decision and recommends upholding the previous eligibility determination __B. Does not concur with the initial eligibility decision and recommends a different determination. Justification (select one) __A. I concur with the initial eligibility determination based on information gathered during the functional assessment, initial application, and any additional follow-up __B. I do not concur with the initial eligibility determination. Additional information provided during the appeal was not addressed in the eligibility review and/or the functional assessment recommendation completed by a skilled clinician. Please specify what new information was provided and why the applicant’s functional abilities are not consistent with initial determination. Community Representative This MetroAccess appeals panelist recommends the following: __A. Concurs with the initial eligibility decision and recommends upholding the previous eligibility determination __B. Does not concur with the initial eligibility decision and recommends a different determination. Justification (select one) __A. I concur with the initial eligibility determination based on information gathered during the functional assessment, initial application, and any additional follow-up __B. I do not concur with the initial eligibility determination. Additional information provided during the appeal was not addressed in the eligibility review and/or the functional assessment recommendation completed by a skilled clinician. Please specify what new information was provided and why the applicant’s functional abilities are not consistent with initial determination.

Capital Metro Paratransit Eligibility Appeal Determination Form F-3 Determination Form HB 695800 Capital Metro Representative This MetroAccess appeals panelist recommends the following: __A. Concurs with the initial eligibility decision and recommends upholding the previous eligibility determination __B. Does not concur with the initial eligibility decision and recommends a different determination. Justification (select one) __A. I concur with the initial eligibility determination based on information gathered during the functional assessment, initial application, and any additional follow-up __B. I do not concur with the initial eligibility determination. Additional information provided during the appeal was not addressed in the eligibility review and/or the functional assessment recommendation completed by a skilled clinician. Please specify what new information was provided and why the applicant’s functional abilities are not consistent with initial determination. For internal CMTA purposes only: Initial Determination Code: ______ Appeal Determination Code: ______ Certification Expiration Date: ___ / ___ /____ CMTA Eligibility Staff Review (signature): _______________________