D. Healthcare Provider Information – To be completed by Healthcare provider ONLY
Physician must complete the first question regarding medical qualification to operate a motor vehicle regardless of the patient’s license status or age. Failure to complete all sections will result in delayed processing and a request for more information about this patient.
In my professional opinion and to a reasonable degree of medical certainty:
The reported condition WILL NOT IMPAIR the safe operation of a motor vehicle.
The person applying for this permit is NOT medically qualified to operate a motor vehicle safely.
The medical condition as stated below is of such severity as to require a COMPETENCY ROAD TEST.
This application is completed for individuals who are severely restricted in mobility/ability to walk due to a neurological, orthopedic, arthritic, or other medically debilitating qualifying condition. I acknowledge the RMV grants disabled parking on the basis of necessity and not as a convenience. Disabled parking misuse carries heavy fines and strict license suspension penalties.
Clinical Diagnosis (Required):______________________________________________ (NO ICD CODES ACCEPTED)
Duration of placard to be issued (check one): Temporary Permanent
If temporary, please estimate number of months of disability: __________
Please check ALL that apply:
Unable to walk 200 feet without stopping to rest; list any necessary ambulatory aids: _____________________________
Legally Blind* (Certificate of Blindness may substitute for professional certification). *automatic loss of license
Chronic Lung Disease To such an extent that the applicant’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than 1 liter (attach most recent FEV1 Test results):
______ FEV 1 test result |
_____ O² saturation with minimal exertion (*automatic loss of license if O² saturation ≤ 88%) |
Use of Portable Oxygen? |
Yes No |
NOTE: Asthma alone is not a qualifying condition. Please describe degree and frequency of impairment (pulmonary function test results are required).
_______________________________________________________________________________________________
Cardiovascular Disease
AHA Functional Classification (check one): I II III IV* (*automatic loss of license)
Loss of Limb or permanent loss of use of a limb (please describe):
E.Healthcare Provider Certification and Signature – All fields must be completed
Provider’s Last Name (please print) |
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Provider’s First Name |
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Provider’s Address |
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Street |
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Apt. # |
City |
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State |
Zip Code |
NPI # |
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Board of Registration in Medicine # |
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Phone # |
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I am a: Medical Doctor |
Chiropractor Registered Nurse |
Physician Assistant Osteopath Optometrist (legal blindness only) |
Podiatrist |
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I certify under the penalty of perjury that the information I have provided is true and correct to the best of my knowledge.
Provider’s Signature: ___________________________________________________________ Date: _______________________