Reduced Fare Application Section 2

Reduced Fare Application Section 2

To be completed by Professional Healthcare Provider/Agency within 30 days of application date

Section 2: Medical Provider Form

In order to qualify for DiriGo Pass Automated Fare System reduced fare, your client/patient listed on this application must have a physical or mental/cognitive condition that falls within the medical eligibility criteria that substantially limits a major life activity, such as caring for one’s self, walking, seeing, hearing, speaking, breathing, learning, and/or working, and that further meets legal standards for reduced fare eligibility listed on page one of this application.
Name of Reduced Fare Applicant
Is this disability permanent?
Note: If the disability is temporary, it must last for at least 90 days to be eligible for reduced fare.
Office address
List the qualifying disability here.
I certify that the information on this application is correct. I give the agency or medical professional permission to release information regarding my disability. I understand that if this application is approved, I will be eligible to receive the reduced fare rate (50% of the regular fare) for the DiriGo Pass Fare System. I will not loan or give use of my card or mobile app to anyone. If paying with cash, I will present my ID card to the bus operator as requested when paying my fare.
Printed name of healthcare professional/ agency representative
MM slash DD slash YYYY
Drop files here or
Accepted file types: jpg, pdf, png, gif, jpeg, , Max. file size: 25 MB, Max. files: 5.
    Certification on provider’s letterhead must be attached.