Form Reg 195 - Application For Disabled Person Placard Or Plates Page 2
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2F.
DOCTOR’S CERTIFICATION OF DISAbILITy
A full legible description of the illness or disability must be provided for numbers 3, 4, 5, 6 and 7 below. A licensed physician, surgeon,
physician’s assistant, nurse practitioner, or certified nurse midwife, may certify to items 1 – 7, a licensed chiropractor may certify to items
5 – 7 only, and a licensed physician or surgeon who specializes in diseases of the eye or a licensed optometrist may only certify to item 8.
my patient ___________________________________________meets the requirements of a disabled person found in CVC 295.5 as he
(PRINTED NAmE OF PATIENT)
or she suffers from the following:
1.
A lung disease to the extent that forced (respiratory) expiratory volume for one second when measured by spirometry is less
than one liter or arterial oxygen tension (pO2) is less than 60 mm/hg on room air while the person is at rest.
2.
A cardiovascular disease to the extent that the person’s functional limitations are classified in severity as class III or class IV
based upon standards accepted by the American heart Association.
3.
A diagnosed disease or disorder which substantially impairs or interferes with mobility due to (please print):
___________________________________________________________________________________________________.
4.
A severe disability in which he or she is unable to move without the aid of an assistive device, which is due to (please print):
___________________________________________________________________________________________________.
5.
A significant limitation in the use of lower extremities due to (please print):
___________________________________________________________________________________________________.
6.
The loss, or loss of the use of one or more lower extremities. Loss of use due to (please print):
___________________________________________________________________________________________________.
7.
The loss, or loss of the use of, both hands. Loss of use due to (please print):
___________________________________________________________________________________________________.
8.
Central visual acuity does not exceed 20/200 in the better eye, with corrective lenses, as measured by the Snellen test, or visual
acuity that is greater than 20/200, but with a limitation in the field of vision such that the widest diameter of the visual field
subtends an angle not greater than 20 degrees.
Please check the appropriate box(es).
PERMANENT PLACARD
TEMPORARy PLACARD
TraVeL PLaCarD
Valid until: month ____ Day____ Year_____
Valid until: month____ Day ____Year _____
(Cannot exceed 6 months)
(Cannot exceed 30 days for a California
resident and 90 days for a non-resident.)
G.
aUThorIZeD MeDICaL ProVIDer’S SIGnaTUre anD CerTIFICaTIon
PRINT AUThORIzED mEDICAL PROVIDER’S LAST NAmE FIRST NAmE mIDDLE NAmE
AUThORIzED mEDICAL PROVIDER’S DAYTImE TELEPhONE #
(
)
AUThORIzED mEDICAL PROVIDER’S ADDRESS
CITY
STATE zIP CODE
I certify that I am a
Physician
Surgeon
Chiropractor
optometrist
Physician’s assistant
nurse
Practitioner
Certified nurse Midwife and I certify (or declare) under penalty of perjury under the laws of the State of California that
the foregoing is true and correct. I also certify that I will retain information sufficient to substantiate this certification and shall make that
information available for inspection by the medical board of California at the department’s request. (CVC Section 22511.55).
EXECUTED AT (CITY, STATE)
DATE
AUThORIzED mEDICAL PROVIDER’S SIGNATURE
MEDICAL LICENSE NuMbER
h.
CerTIFICaTIon oF reaDILY oBSerVaBLe anD UnConTeSTeD PerManenT DISaBILITY (DMV USE ONLY)
SIGNATURE OF DmV EmPLOYEE
LINE DATE STAmP
When this form is completed, it may be mailed to:
DmV Placard
P.O. box 942869
Sacramento, CA 94269-0001
or submitted to your nearest DmV office. It is recommended that you make an appointment if submitting this form to your nearest
DmV office, by calling 1-800-777-0133.
REG 195 (REV. 8/2008) WWW
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