New Rider Form (electronic)

The Ohio Department of Aging monitors the effectiveness of programs offered to Ohio senior citizens. The data collected (age, sex, race, low-income status, Activities, and Instrumental Activities of Daily Living) is forwarded to the Area Agency on Aging and the Ohio Department of Aging. The 1992 Older Americans' Act reauthorization requires this information to be summarized and reported to the Administration on Aging to keep state and federal legislators informed on the effectiveness of senior programs.

All information will be kept confidential and no personal identifying information will be released to the public without written consent, unless required under federal law.

Although all persons receiving services under the Older Americans' Act are asked to provide this information, no person may be denied services for refusing to provide any of the requested information.

The transportation provider discloses information to the Union County Human Services for the purpose of determining eligibility for cash assistance, medical assistance, and/or food stamp benefits, Senior Services Sales Tax Levy, or Ohio Department of Transportation Specialized Transportation for the following reasons: permission to verify information electronically, verbally, and in writing if a client is eligible for transportation.

I have read the Release of Information statement and understand that the information is reported to Administration of Aging, Union County Human Services, and other transportation providers. This authorization shall be in place until revoked by client. I have the right to revoke or cancel this authorization at any time by providing notice in writing to the following address: Union County Human Services, PO Box 389, Marysville OH 43040.

See UNION COUNTY AGENCY TRANSPORTATION SERVICE (UCATS) NEW RIDER INFORMATION for more information, terms, and conditions.