Membership Application Form

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WHAT IS THE ACT TAXI SUBSIDY SCHEME?

The Taxi Subsidy Scheme (TSS) subsidises the transport costs of eligible individuals who are

unable to use public transport due to a severe or profound activity limitation. This supports

social inclusion and economic participation of community members who would otherwise be

at risk of social isolation.

ELIGIBILITY:

To be eligible for the ACT Taxi Subsidy Scheme, you must:

1. Be a permanent resident of the ACT or an asylum seeker with proof of status from

Companion House.

2. Have a severe or profound activity limitation that prevents you from using public

transport including:

a. Severe mobility limitation (details of which must be provided);

b. Legal blindness or Severe vision impairment;

c. Cognitive/intellectual/psychiatric disability; and/or

d. Severe and uncontrolled epilepsy.

3. Not be a member of an Interstate Taxi Subsidy Scheme.

FACTORS THAT WILL NOT BE USED TO DETERMINE ELIGIBILITY:

• Income;

• Eligibility for other subsidy, concession or pension schemes within the ACT;

• Availability of, or proximity to, public transport; and

• Length of journey or timetable problems or inconvenience when using public transport.

APPLYING FOR MEMBERSHIP:

To apply for membership with the ACT Taxi Subsidy Scheme you need to:

1. Part A - Complete and sign the declaration in the attached application form;

2. Part B - Take the form to an authorised medical professional/ OT to complete;

3. Enclose a photocopy of a document demonstrating permanent ACT residency. (e.g.:

Current Centrelink Card, Utilities Account, Bank Statement, ACT Services Access Card)

4. Enclose a passport size photograph;

5. In a situation where an applicant is unable to complete or sign an application, please

provide either Guardian or Power of Attorney certified documentation.

6. The completed application form and supporting documentation can be emailed to

concession[email protected] or alternatively, post to:

ACT Taxi Subsidy Scheme

ACT Revenue Office

PO Box 293

CIVIC SQUARE ACT 2608

Applicants will be notified on the outcome of assessment with 25 working days unless further

information is required.

Applicants deemed ineligible for scheme membership may request an internal review of the

decision within 30 days from the date of notification. Request for an internal review needs to

be made in writing with further supporting documentation from a health care professional

e.g. GP, Specialist, Physiotherapist.

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APPLICANT CHECKLIST

Please tick the following once completed:

PART A

Personal Details & Questions

Declaration Signed

PART B - Medical Practitioner/Occupational Therapist

Completed by health professional as indicated for relevant criteria

Doctor/ Occupational Therapist Signature

PROOF OF RESIDENCY

A Photocopy of a document demonstrating Permanent ACT Residency

Example: Current Centrelink card, Utilities Account, Bank Statement, ACT Services Access Car)

PHOTOGRAPH FOR SMARTCARD

One passport size photograph

Please note that if these areas are incomplete, your application will be returned to you.

Please send your completed application with proof of residency to concessions@act.gov.au

or alternatively, post to:

ACT Taxi Subsidy Scheme

ACT Revenue Office

PO Box 293

CIVIC SQUARE ACT 2608

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PART A - MEMBERSHIP APPLICATION FORM

Applicant to complete all of Part A, sign the declaration & provide proof of residency.

(PRINT clearly)

FAMILY NAME:

FIRST NAME:

MIDDLE NAME (S):

DATE OF BIRTH:

CURRENT RESIDENTIAL ADDRESS:

Street name & number:

Suburb:

State: Postcode:

POSTAL ADDRESS:

(If different from above)

Street name & number:

Suburb:

State: Postcode:

DAYTIME TELEPHONE:

( ........ )

MOBILE NUMBER:

EMAIL ADDRESS:

ALTERNATIVE CONTACT PERSON

NAME OF CONTACT:

RELATIONSHIP TO APPLICANT:

CONTACT PHONE NUMBER:

EMAIL ADDRESS:

Office Use Only

Date Received...................................

Signature...........................................

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YES NO

1. Are you a permanent resident of the ACT?

2. Have you previously applied for or joined the ACT Scheme?

3. Are you a member of an interstate taxi subsidy scheme?

4. Do you require assistance with communication/language?

Assistance required: .......................................................................................................................

5. Are you able to use a standard taxi? (No, if Wheelchair Taxi Required)

6. Does your disability affect your ability to use the bus?

Additional Comments / Information: …………………………………………………………………………………….

.............................................................................................................................................

DECLARATION

The information you are asked to provide on this form will be kept confidential and only used

to determine eligibility for membership of the Scheme and to inform the ACT Government of

transport needs for people with disabilities.

I certify that I am unable to use public transport due to my disability and that the

information provided on this form is correct.

I understand that I may be required to undergo a medical examination to be carried out

by a third party health services provider in order to determine eligibility for the Scheme.

I understand that if my application is approved, I may be required to undergo periodic

reviews to confirm my continued eligibility to access the subsidy.

If this application is approved I will abide by the conditions governing the use of this

scheme and acknowledge that any misuse of the subsidy provided may lead to the cancellation

of membership and/or legal action.

I authorise my application form to be forwarded to a third party health services provider

for assessment.

I consent to my doctor or occupation therapist providing the necessary information

required by the ACT Taxi Subsidy Scheme for the purpose of assessing my eligibility for

membership of the Scheme.

I consent to my information being provided to Cabcharge and to be used to inform the

ACT Government of transport needs for people with disabilities.

NAME OF APPLICANT:

SIGNATURE OF APPLICANT:

DATE SIGNED:

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PART B - MEDICAL PRACTIONER/OCCUPATIONAL THERAPIST TO COMPLETE

Must be completed by a Medical Practitioner or Occupational Therapist.

The Taxi Subsidy Scheme is intended to improve the mobility and independence of people who are

unable to use public transport because of severe or profound activity limitations. It is not intended to

remedy the limitations of public transport coverage or frequency.

A severe disability for the purposes of the ACT Taxi Subsidy Scheme means:

1. Severe mobility limitation;

2. Legal blindness, as defined for social security purposes;

3. Severe vision impairment;

4. Severe Cognitive/intellectual/psychiatric impairment;

5. Severe and uncontrolled epilepsy.

A designated ACT Government officer will make the final assessment regarding the approval of

this application based on the information provided in this form.

For our assessment of this application, your responses to the following questions are essential.

All information will be treated confidentially. If you wish to discuss your situation please phone

(02) 6207 0028

NAME: DOB:

DIAGNOSIS OR DISABILITY

Please provide details of the applicant’s diagnosis or disability that are relevant to their ability

to use public transportation:

DIAGNOSIS OR DISABILITY (Please do not use acronyms) DATE OF ONSET

Please Note: If all the required information is not provided the application will be returned to

your patient/client for full completion.

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1. Does the applicant’s disability prevent them using public transport?

Always Usually Sometimes Never Unsure

2. Is the applicant undergoing active treatment or rehabilitation? Yes No

3. Is the applicant’s condition likely to:

Deteriorate Stay the same Improve Don’t Know

RECOMMENDED PERIOD OF MEMBERSHIP:

Temporary Membership

(For temporary or short term conditions which prevent the use of public transport for

designated period of time. Please indicate when you expect the person to stabilise or regain

enough function to be able to use public transport):

3 mths or less 6mths 12 mths 18 mths 2 years 3 years

Permanent Membership

(For conditions which are permanent or unlikely to improve)

LOSS OF FUNCTION

Please tick the eligibility category or categories that apply in relation to this application:

Severe Mobility Limitation

Legal Blindness or Severe Vision Impairment

Severe Cognitive/Intellectual/Psychiatric impairment

Severe and uncontrolled Epilepsy

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CATEGORY 1 - MOBILITY

1.1 Does the applicant experience a physical

impairment (e.g. paralysis,

Loss of limb(s), arthritis, circulatory or

Respiratory diseases) which affects their

capacity to use public transport?

Yes No

1.2 Does the applicant use a walking aid?

Yes No

1.3 If yes, what type of aid is used?

Walking frame

Wheeled Walking Frame

Crutches

Walking stick

Wheelchair

Scooter

Other Aid

1.4 Does the applicant permanently require

use of a wheelchair?

Yes No

1.5 Is the applicant able to use a standard

taxi?

Yes No

1.6 How does the applicant’s mobility

limitation affect their ability to use public

transport?

.....................................................................

CATEGORY 2 - VISION

2.1 Is the applicant visually impaired?

Yes No

2.2 Does the applicant meet the eligibility

criteria for legal blindness?

Yes No

2.3 What is the applicant’s best corrected

visual acuity using the Snellen Scale?

Right eye

Left eye

2.4 Please give details of any visual field loss

(in degrees).

Right eye

Left eye

2.5 How does the applicant’s vision

impairment affect their ability to use public

transport?

.....................................................................

CATEGORY 3 – COGNITIVE,

INTELLECTUAL OR PSYCHIATRIC

3.1 Does the applicant have one of the

following impairments?

Cognitive

Intellectual

Psychiatric

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3.2 How does the applicant’s cognitive,

intellectual, or psychiatric impairment affect

their ability to use public transport?

.....................................................................

3.3 Is the applicant undergoing or have they

undergone, special travel training?

Yes No

3.5 If yes, please comment on the expected

outcome of this training.

....................................................................

CATEGORY 4 - EPILEPSY

4.1 Does the applicant have a diagnosis of

severe and uncontrolled epilepsy?

Yes No

4.2 If Yes, please comment on episode history

....................................................................

4.3 How does the applicant’s epilepsy affect

their ability to use public transport?

.....................................................................

Other Comments

..........................................................................

APPROVED HEALTH PRACTITIONERS

DETAILS

Doctor’s/Occupational Therapist’s Name

(please print)

………………………………………………………………….....

……………………………………………...........................

Qualification(s)

………………………………………………………………........

……………………………………………...........................

Work Address:

……..…………………...………....................................

……………………………………………............................

Suburb: ……………….……...…................................

Post Code: …….……………………...…….…................

Phone No (02) ……...………………..….....................

Email:…….……………………...…….…........................

Medical or other Health Professional Board

Registration No. or Medicare Provider No

………………………………………………….………........

……………………………………………......................

I CERTIFY THAT I HAVE COMPLETED THE

RELEVANT DETAILS IN PART B AND THAT THIS

INFORMATION IS CORRECT TO MY

KNOWLEDGE.

Signature:

Date:

Medical Stamp:

Thank you for your assistance

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SMARTCARD PHOTO IDENTIFICATION

NAME OF APPLICANT:

The photograph must:

• Be no more than six months old

• Be passport size, which is 45-50mm high and 35-40mm wide

• Be in colour

• If printing a hard copy photograph, it must be printed on photo-quality paper without visible

pixels or dot patterns

• Have plain, light coloured background

• Show applicant’s head and top of shoulders

• Show the applicant looking directly at the camera with eyes open (if possible)

• Show the applicant with his/her hat and sunglasses removed

• A high resolution colour photo can be taken by a mobile phone and emailed with your

application

If attaching the photo to the above form, please use a paperclip only, DO NOT pin, staple or glue

your photograph to this form.

Please note it will take approximately 10 working days for the processing of your ACT Taxi

Smartcard.