Medium

Available on

Apple Android Windows

Disability Verification Form Mobile App

If you are disabled between 18 and 54 years of age, please have the Disability Verification For mobile app completed by a medical specialist. Complete the application and the disability form and submit when proof of disability is required for services.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Disability Verification Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    NOTE: If you are disabled between 18 and54 years of age, please have this form completed by a med...

  • Ico statictext

    To the Qualifying Person:

  • Ico statictext

    County Department of Aging operates a subsidized taxi transportation program designed to provide ...

  • Ico multiline

    What is the person’s diagnosis?

  • Ico multiline

    How does the disability prevent use of public transportation?

  • Ico textbox

    How long will the disability continue?

  • Ico textbox

    I recommend certification of

  • Ico statictext

    for the Transit Service.

  • Ico textbox

    (Person’s name)

  • Ico textbox

    (Name of recommending person)

  • Ico textbox

    (Agency of professional license)

  • Ico signature

    (Signature of recommending person)

  • Ico textbox

    (Title)

  • Ico date

    (Date)

  • Ico textbox

    Phone No.

  • Ico multiline

    Address

  • ...and More!

Related Health Care & Social Services Apps... and they're all free for GoCanvas subscribers!

App Name

Assisted Living Resident Accident In...

The Assisted Living Resident Accident Incident Report mobile app provides a simple form for long-term care facilities, inc...

App Name

Evaluate Hospice Services

Use this app to evaluate hospice services to determine which one will work best for you and your loved one. Covers all the...

App Name

Facesheet

The Patient Facesheet Mobile App helps you create a document that gives a patient’s medical records at a quick glance. Thi...

App Name

Adult Day Care Licensure and Certific...

Adult day care programs are organized community groups that offer social opportunities and healthy interaction for those w...

App Name

Pain Management : Management

The Pain Management: Management mobile app provides procedures concerning the management of pain for people who have a pro...

App Name

Adult Day Care Licensure and Certific...

The Mississippi Department of Human Services, Division of Aging and Adult Services administers and monitors adult day care...

App Name

Senior Facilities Emergency Planning ...

A fire or other emergency within your facility can pose unique problems for management, staff, residents, and the emerg...

App Name

Adult Patients with Medical Decision ...

The Adult Patients with Medical Decision Making Capacity (Any Setting) Checklist mobile app includes a 12 step checklist f...

More Information