Disabled Tap Identification Card Application Form Page 2
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4this side to be completed for qualifying medical disability criteria only
section iv – medical release consent (required for medical disability criteria only)
In connection with my application for a
Disabled
card, I hereby authorize Dr.________________________________ to release
LACTOA
TAP
to the appropriate agency, medical or other pertinent information regarding my disability. The information released will only be used to
verify my patient status and the designation of my disability category.
I realize that I have a right to receive a copy of this authorization. I understand that I may revoke this authorization at any time. Unless
revoked, this form will permit the health care professional certifying my disability to release pertinent information for up to 60 days after
the date appearing below.
Applicant Name (Print)
Applicant Signature
Date
section v – medical professional certification (for doctor’s use only)
Qualified health care professionals who may certify disabilities listed in section vi:
m.d. & d.o. – all impairments,
all categories
audiologist – hearing impairments
O, P only
chiropractors – mobility impairments
A, B, D only
podiatrist – mobility impairments
A, B, C, D only
optometrist – visual impairments
K, L only
clinical psychologists – mental impairments
M, N only
In order to certify an individual for the
Disabled
card you must:
LACTOA
TAP
>
Agree to only certify, as eligible, those individuals who meet the criteria in section vi.
>
Upon request, provide verification of the information contained on this application to qualifying agency.
>
Possess the proper professional degree and be licensed in California.
I hereby certify that the applicant’s Medical Disability Criteria defined in section vi is/are (circle all letters that apply)
A B C D E F G H I J K L M N O P
In the space provided below, doctor must indicate in detail applicant’s disability. (required)
In my professional judgment the applicant’s disability is expected to continue for (
) years, (
) months.
(Note:
TAP
Identification Cards will not be issued for less than 3 months or more than 3 years.)
I understand that failure to certify applicant disabilities in accordance with the above guidelines will result in cancellation of my certification
privileges. I am legally licensed as a
in the State of California and under the penalty of perjury,
enter title of qualified profession
I hereby declare that the information provided is true and correct.
medical professional information
Doctor’s Full Name
License No.
Address
Suite
City | State | Zip
Telephone Number
Fax Number
Signature
Date of Execution
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