Form 1776 - Physician'S Statement For Disabled License Plates/placard Page 2
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2TEMPORARY PLACARD INFORMATION
Upon expiration, a Temporary Placard may be renewed once for an additional 180
days, provided the applicant reapplies and submits a new Physician’s Statement for
Disabled License Plates and/or Placards (DOR-1776). If the temporary period of
disability is not specified by an advance practice registered nurse, licensed physician,
chiropractor, physician’s assistant, podiatrist or optometrist, a Temporary Placard will
be issued only for a period of 30 days.
RESPONSIBILITIES OF ADVANCE PRACTICE REGISTERED NURSE,
LICENSED PHYSICIAN, CHIROPRACTOR, PHYSICIAN’S ASSISTANT,
PODIATRIST OR OPTOMETRIST
An advance practice registered nurse, licensed physician, chiropractor, physician’s
assistant, podiatrist or optometrist who issues and signs this form shall maintain a
copy of this form in the disabled person’s medical chart and maintain sufficient
documentation as to objectively confirm that such a condition exists. A chiropractor,
podiatrist, or optometrist may only issue and sign this form for those conditions which
he or she is legally authorized to diagnose and treat.
The medical or other records of the advance practice registered nurse, licensed
physician, chiropractor, physician’s assistant, podiatrist or optometrist who issued
and signed this form shall be open to inspection and review by such practitioner’s
licensing board, in order to verify compliance. Information contained within such
records shall be confidential unless required for prosecution, disciplinary purposes,
or otherwise required to be disclosed by law.
MO 860-0412 (08-2010)
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