Gold Card Impairment Certification Form printable pdf download

Gold Card Impairment Certification Form

If you are applying for a Gold Card due to a medically verified physical or cognitive condition,

impairment, or disability this form must be completed and signed by a licensed medical professional.

Accepted medical professionals include:

• Medical Doctor

• Audiologist

• Registered Nurse

• Doctor of Osteopathic Medicine

• Ophthalmologist

• Physical Therapist

• Doctor of Chiropractic

• Psychologist

• Licensed Practical Nurse

• Occupational Therapist—Licensed and Registered

Be sure to print your name and date of birth

Last Name ____________________________ First Name _________________________ MI_____

Date of Birth ____ - _____ - ______

Address

________________________________________________

Must be completed by Medical Professional

Dear Medical Professional:

In order to process this applicant’s request for SCAT Gold Card eligibility, we require this form be

completed. Only licensed medical professionals having knowledge of the applicant’s functional

ability should complete this form.

Please return the completed Impairment Form to the customer, or fax directly to our office at

(941) 861-1011. Thank you.

Has this person been diagnosed with a cognitive, mental, physical, or other disability?

If yes, please list and explain ___________________________________________________________

__________________________________________________________________________________

How long has this disability been present? ______

If temporary, how long? ______________________________________________________________

Please describe any other medical conditions this person has at this time and severity, in detail,

including any restrictions, limitation, and prognosis _________________________________________

__________________________________________________________________________________

SCAT Gold Card Impairment Certifiaction Form

December 2013

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Gold Card Impairment Certification Form