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Eligibility Determination Appeals Request Form

PURPOSE:    To request a review of the decision to deny or a review of the decision to grant only temporary or conditional ADA Paratransit eligibility.

Instructions for Filing an Appeal of your Individual Eligibility Determination for Paratransit Services:

Step 1.          Complete the “Eligibility Determination Appeals Request Form”. Completed Forms must be submitted within sixty (60) calendar days of the date of denial stated on the “letter of denial”. For example, if your denial date is March 1st, the deadline for submittal of the Eligibility Determination Appeals Request Form is May 1st. The completed Eligibility Determination Appeals Request may include any additional information supporting eligibility for Paratransit services, but this is not required.

Step 2.          The Eligibility Determination Appeals Request Form and any additional supporting information must be submitted to the Manager of the Paratransit Eligibility Services. It may be sent to the following address: 

San Francisco Paratransit
68-12th Street, 1st Floor
San Francisco, CA 94103-1297

Upon receipt, the Eligibility Determination Appeals Request Form is immediately date-stamped, and an appeals hearing will be scheduled within a reasonable timeframe.

If an appeal form is not submitted within 60 days, no hearing will be held; the appellant has missed the opportunity to appeal.

Step 3.          Paratransit Eligibility Appeals Panel Hearing Description

                       The Appeals Panel is generally comprised of one public transit professional representative, one Paratransit consumer representative and one medical professional representative.

(Panel Members will disqualify themselves at the hearing should they have a conflict-of-interest that would bias their decision on the individual’s eligibility appeal.)

All information will be treated as confidential by Panel Members and staff.

Appellant and/or a representative will be notified of hearing date, time and location. Appellant is strongly encouraged to attend hearing. If appellant chooses, he or she may be accompanied by one representative and/or one attendant. The appellant or representative need not be present at hearing. If needed, appellant may request that an interpreter be provided.

On the day of the hearing:

1.     Staff introduces appellant to Panel Members and reviews determination of eligibility of Paratransit.

2.     Appellant and staff each have equal time (10 minutes) to present information specific to eligibility before Appeals Panel.

3.     Panel members may ask questions, after presentation by staff and appellant at their discretion.

4.     Panel members discuss appellant’s case, and information presented after appellant and staff are excused. Panel members shall deliberate as necessary.

5.     Panel members will then:

·        reach a conclusion on eligibility

·        state reasons for decision to overturn or uphold staff’s original decision

Panel members may instruct staff as to follow-up with appellant.

6.     The Appeals Panel decision is communicated in writing within 30 days of the appeals hearing. If a panel decision is not made by the 31st day, appellant may use Paratransit services until a decision is made.

The appeals hearing is the final administrative step in the eligibility determination process. Appellant may reapply if his/her condition changes.

Para obtener mas información, por favor de llamar al 1-415-351-7004.

了解更多信息, 請打 1-415-351-7005.

Чтобы получить больше информации, Пожалуйста позвоните по телефону 1-415-351-7006.

 

 ELIGIBILITY DETERMINATION APPEALS REQUEST FORM

(1) Name: ___________________________________________________

Address: ___________________________________________________

City: __________________________ State: ______ Zip: ________

Phone: ___________________________________________________

(2) Representative, if any:  Name: _________________________________

Title: ___________________________________________________

Address: ___________________________________________________

City: __________________________ State: ______ Zip: ________

Phone: ___________________________________________________

(3) Will you need SF Paratransit to provide a language or American Sign Language (ASL) interpreter for the hearing?

____ NO, I will not need an interpreter.

____ Yes, I will need an interpreter at the Appeals Hearing.

     State language you speak or if you need an ASL interpreter:

_____________________________

____ Please provide an interpreter for me. OR

____ I will provide my own interpreter.

(4) Will you need SF Paratransit to provide transportation for you to the hearing?

____ NO, I do not need transportation.

____ YES, I will need transportation


If you have any additional related information to support your case, please submit at any time prior to or on the date of the Appeals Hearing.  Please refer to the enclosed instructions for more information on where to send additional information.

It is in the best interest of the Appellant to appear in person before the Appeals Panel. Please note that the hearing will proceed and a decision will be made whether or not the appellant is present. If you cannot attend the hearing or if you need to reschedule, you MUST notify our office 5 business days in advance.


 

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