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Affidavit of Disability and Release of Medical Information

  1. I authorize the release of medical information to the City of Port Arthur Transit to complete the application process for ADA Paratransit Services.
  2. To be Completed by The Physician
  3. Is this disability
    Select one
  4. Does the applicant require a personal care attendant?
  5. Does the applicant have any restrictions?
  6. Physician's Signature
  7. Leave This Blank: