Application For Disabled Placard/plate - Massachusetts Registry Of Motor Vehicles (Page 2 of 4) in pdf

A Healthcare Provider is defined as a Medical Doctor, Optometrist, Chiropractor, Podiatrist, Registered Nurse or

Physician Assistant who is licensed to practice in the Commonwealth of Massachusetts.

Dear Healthcare Provider:

This is an application to allow your patient to display a disabled license plate or a disabled placard. Both items will allow your patient

to park in specially designated “handicapped” parking spaces designed to increase access for people with impaired mobility.

The medical criteria you fill out below will enable the RMV to determine if your patient qualifies for the privilege of access to these few

and select parking spaces. Should your patient's medical condition raise a concern as to his or her ability to drive safely, the RMV

may request that the individual take a competency road test, or, if the individual poses an immediate threat, ask him or her to

surrender his or her driver's license.

The individual's ability to hold a driver's license will not affect his or her ability to obtain a plate or placard. If you determine that your

patient's medical condition renders him or her a threat to his or her own safety and to the safety of others using the roadways, please

so indicate on this application.

Please be as accurate and detailed as possible to ensure that a fair evaluation of your patient's application may be made by the RMV.

Please check which conditions, if any, accurately describe the person applying for this permit:

Has been declared legally blind (please attach copy of certification). Applicants in this classification

must surrender their driver's license.

Is restricted by lung disease to such a degree that the person's forced (respiratory) expiratory

volume (FEV) in one second, when measured by spirometry, is less than one liter; OR

The person's oxygen saturation level is 88% or less, even with supplemental O

. Applicants whose

saturation level is 88% or less, even with supplemental O

, MUST surrender their driver's license.

Uses portable oxygen.

Has a Class III cardiac condition according to the standards set by the American Heart Association

(See Classification Guidelines).

Has a Class IV cardiac condition according to the standards set by the American Heart Association

(See Classification Guidelines). Applicants in this classification must surrender their driver's license.

Cannot walk 200 feet without stopping to rest. Please state clinical diagnosis and exact nature of

impairment:

Cannot walk without the assistance of another person, prosthetic aid, or other assistive device.

Please state device used

and exact nature of impairment:

Has lost one or more limbs or permanently lost the use of one or more limbs. Please describe:

If any of the above conditions are due to an arthritis condition, please state:

Type of Arthritis Condition

All Joint(s) and/or all Limb(s) Affected

Symptoms Experienced (functional status) ____________________________________________

Is the applicant able to perform self care?

Yes

Application For Disabled Placard/plate - Massachusetts Registry Of Motor Vehicles Page 2