STEP Transportation Certification of Application Form

I hereby certify that to the best of my knowledge, the information contained herein is true, correct and complete.

I understand and agree to the following:

1. The purpose of this evaluation is to help in determine the most cost effective and appropriate mode of transportation for me.
2. I will report any changes in circumstances immediately to the STEP Transportation.
3. Documentation of all eligibility factors may be required to determine eligibility correctly or for auditing purposes and that giving knowingly false statements is a criminal offense.
4. MATP customers only: I have a right to request a Department of Human Services fair hearing if Medical Assistance Transportation benefits are denied. This affirmation statement covers all attachments required for the determination of eligibility.
5. MATP customers only: If I fail to provide or fully disclose the information requested regarding ownership of, or access to a vehicle my MATP services may be suspended or terminated.
6. I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility.

I attest that the answers to the above questions are true and honest to the best of my ability.

By signing, I affirm that to the best of my knowledge, the information in this evaluation form is true and correct. Furthermore, I certify that I have medical information on file to document the above statements and will produce such documentation at the request of the Medical Assistance Transportation Program or Shared-Ride Provider. I understand that providing false or misleading information could result in prosecution allowed by the laws of the Commonwealth of Pennsylvania.

I have been given all of the policies and procedures paperwork pertaining to this program and understand them to the best of my knowledge, including the scheduling procedures and times.

55 Pa. Code § 2070.25 requires providers of medical service to give access to and allow the use and disclosure of information on applicants and clients to: Federal authorities, the Commonwealth, the Department, the county commissioners or county executive, and prime contractors or their authorized agents, if the information is necessary to the administration of the Public Assistance
Transportation Block Grant.

I hereby authorize my representatives to release any and all information required by STEP Transportation for the purpose of determining an appropriate method for the purpose of transporting me to various services.

I hereby authorize and request the disclosure of medical information to the Medical Assistance Transportation Program. I also hereby authorize the release of any information concerning the age, residence, citizenship, employment, education and training activities, and any additional information, including medical information and treatment plans, pertaining to eligibility for Medical Assistance Transportation and /or specific transportation requests under MATP. It is understood that
the information obtained will be used only for purposes directly related to the Medical Assistance Transportation Program or the Shared-Ride Transportation Program.

STEP Transportation reserves the right to verify all information with the Pennsylvania Department of Transportation (PennDOT) as well as the Department of Human Services. Failure to disclose complete and accurate information may result in suspension or termination of MATP/Shared-Ride services.