Application For Disabled Placard/plate - Massachusetts Registry Of Motor Vehicles (Page 3 of 4) in pdf

Application For Disabled Placard/plate - Massachusetts Registry Of Motor Vehicles Page 3

LENGTH OF DISABILITY

Condition is permanent (in excess of two years)

Condition is temporary—expected duration (in months) ______

(minimum 2 months, maximum 24 months)

HEALTHCARE PROVIDER MUST CHECK ONE OF THE FOLLOWING STATEMENTS

In my professional opinion and to a reasonable degree of certainty:

The person applying for this permit is medically qualified to operate a motor vehicle safely.

I am unable to determine ability; I request that the person applying for this permit take a competency

road test to determine his or her ability to operate a motor vehicle safely and/or undergo an

assessment to determine whether any adaptive equipment or appropriate restrictions are necessary to

ensure that he or she is able to operate a motor vehicle safely.

The person applying for this permit is not medically qualified to operate a motor vehicle safely.

HEALTHCARE PROVIDER CERTIFICATION

I hereby certify, under pains and penalties of perjury, that the information I have provided herein is true, accurate, and

complete.

Please Print

Certifying Healthcare Provider's Name

Provider's Title

Mass Board of Registration Number

Address (City/Town/State/Zip Code)

Telephone Number

Date

Certifying Healthcare Provider's Signature

CLASSIFICATION GUIDELINES

ATTENTION Healthcare Provider

Please use the following list to complete the application to the left:

American Heart Association Functional Classification System

Class I

Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity

does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

Class II

Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest.

Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

Class III

Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at

rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea or anginal pain.

Class IV

Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.

Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any

physical activity is undertaken, discomfort is increased.

Application For Disabled Placard/plate - Massachusetts Registry Of Motor Vehicles Page 3