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    Area Agency on Aging

    The Ventura County Area Agency on Aging is a division of the Human Services Agency (HSA).

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Home > Our Services > Transportation > Transportation Online Referral Form

Transportation Online Referral Form

"*" indicates required fields

Name*
Address*
Mailing address different from above?*
Mailing Address
MM slash DD slash YYYY
Preferred method of contact for appointment:*
What is the best time to reach you?*
:
Preferred language?*

SOCIAL HISTORY

Marital Status:*
Race*

Ethnicity*

THE GAY BISEXUAL AND TRANSGENDER DISPARITIES REDUCTION ACT OF 2016 (AB 959)

What is your gender?*
What was your sex at birth?*
How do you describe your sexual orientation or sexual identity?*

MILITARY SERVICE

Have you ever served in the United States military?*
Are you the spouse, legal partner, parent, or child of a person who is serving, or who has served, in the United States military?*
If you answered yes to either of the last two questions, do you consent to this agency and the California Department of Aging transmitting your name, email address, mailing address, and telephone number(s) to the Department of Veterans Affairs only for the purpose of receiving additional information on veterans benefits for which you may be eligible? I understand that this consent is valid for 12 months from the date of signature.*
Contact the California Department of Veterans Affairs (CalVet) to determine eligibility for services and supports at www.calvet.ca.gov or (800) 952-5626. You can also contact the Ventura County Veteran Services office at (805) 477-5155 for more information.

PLEASE LOOK AT YOUR PRESCRIPTION DRUG CARD / HEALTH PLAN CARD AND LOOK FOR PDP OR HMO

Do you have Medicare Part A?*
Do you have Medicare Part B?*
Do you have a Medicare Stand Alone Part D Plan (PDP)?*
Do you have an HMO Medicare Advantage (Plan C)?*
Do you receive prescription drug coverage from a retiree, union or employer plan?*

YOU MAY BE ELIGIBLE TO SAVE ON PRESCRIPTION DRUG COSTS & QUALIFY FOR OTHER PROGRAMS

Are you on Medi-Cal?*
Interested in applying?*
Are you receiving CalFresh benefits?*
Interested in applying?*
Is your MONTHLY GROSS INCOME LESS than $2,510 for one person or $3,408 for two people purchasing and preparing food together?*
Are your ASSETS (bank and IRA accounts) LESS than $17,600 if single or $35,130 if married?*
Is your MONTHLY GROSS INCOME LESS than $1,903 if single or $2,575 if married?*
Are you interested in receiving help paying for your home energy bills, certain repairs, and/or weatherization projects?*

PRESCRIPTION DRUGS

The information you provide will inform our comparison. TIP: Pull out your medication bottles and transcribe the full name of the drug(s) into the field(s) below.
Please list the specifics for each of your prescription drugs. Click on the + sign at the end to add more fields if necessary.*
Name of Drug
Dosage (how many mg)
How Often (# per day/week/mo)
Brand Name Required? (Y/N)
 
Please list name of drug / Dosage (how many mg) / How often (#per day/week/mo/yr)
Name of Drug
Dosage (how many mg)
How Often (# per day/week/mo)
Brand Name Required? (Y/N)
 
Please list name of drug / Dosage (how many mg) / How often (#per day/week/mo/yr)
Name of Drug
Dosage (how many mg)
How Often (# per day/week/mo)
Brand Name Required? (Y/N)
 
Please list name of drug / Dosage (how many mg) / How often (#per day/week/mo/yr)
Name of Drug
Dosage (how many mg)
How Often (# per day/week/mo)
Brand Name Required? (Y/N)
 
Please list name of drug / Dosage (how many mg) / How often (#per day/week/mo/yr)
Name of Drug
Dosage (how many mg)
How Often (# per day/week/mo)
Brand Name Required? (Y/N)
 

ADDITIONAL INFORMATION

How did you hear about us?*

DISCLOSURE STATEMENT

HICAP counseling services are provided by trained counselors, registered by the California Department of Aging, who are acting in good faith to provide independent, impartial information about health insurance policies and benefits to clients. Counselors do not sell any type of health care coverage. They do not endorse or recommend any specific plan or policy. Information presented by HICAP volunteers should not be construed to be legal advice, and volunteers are not liable for acts and omissions in providing counseling to recipients of service. Welfare and Institutions Code, Section 9541 (1)(4)
MM slash DD slash YYYY

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Location and Contact

  • Ventura County Area Agency on Aging
  • 4651 Telephone Rd., Ventura, CA 93003
  • 805-477-7300
  • LOIS.VCAAA@ventura.org
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Quick Links

  • Caregiving
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Resources

  • Resource Directory
  • 211 Ventura County
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