Application For Accessible Parking Space Program Driver Only Application Page 3
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4REVISED May 1, 2014 – Previous Versions No Longer Valid
CITY OF BOSTON
Application for Residential Accessible Parking Space Program
Medical Documentation Form
This form must be filled out completely by the applicant’s Primary Care Physician or a Licensed Specialist.
Information must include the Physician’s registration number and their signature. Please type or print clearly.
Instructions for Physician: Your patient, named above, is applying for a Residential Accessible Parking Space (APS space) in the
City of Boston. To qualify for this program, we need specific information from you about your patient’s medical diagnosis and
functional limitations. A person must have a physical limitation which prevents them from getting to their home from an on-street
parking space farther than one block away. Please read this form in its entirety and complete it accurately to the best of your
knowledge ONLY for those patients who you have personally treated and diagnosed with a severely limited ability to walk.
Date: _____________________________________
Patient (Applicant) Name: ____________________________________________ Date of Birth: _________________________
Doctor’s Relationship to Patient: PCP Specialist Other Specialty/Other: ___________________________
Describe Patient DIAGNOSIS: ______________________________________________________________________________
Is this a permanent condition?
Yes
No
If this condition is temporary, how long do you expect it to last? ____________________________________________
Describe Patient SYMPTOMS: _____________________________________________________________________________
_______________________________________________________________________________________________________
How does this medical condition affect their ability to walk? ____________________________________________________
_______________________________________________________________________________________________________
1 ½
How many city blocks can this patient walk?
1
2
3
Other ___________________
Have you prescribed any medically necessary mobility devices for this patient?
Yes
No
If “yes,” which devices have you prescribed?
wheelchair
portable oxygen
cane
other ___________
How long has this patient been under your care for this condition? _______________________________________________
How often do you see this patient? Annually Monthly Weekly
Other __________________________
Does this patient receive medical treatment / therapy outside of their home on a regular basis? Yes
No
If ”Yes,” what treatment / therapy do they receive? _______________________________________________________
How often do they leave their home for this treatment? Daily
Weekly
Other __________________
*** A copy of your prescriptions for all mobility devices MUST be enclosed with application ***
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