MASSACHUSETTS REGISTRY OF MOTOR VEHICLES
Medical Affairs Branch
PO Box 199100
Boston, MA 02119-9100
Telephone: (617) 351-9222
For Hand Deliveries:
630 Washington St., Boston
APPLICATION FOR DISABLED PLACARD/PLATE
THIS SIDE OF THE APPLICATION MUST BE COMPLETED IN THE DISABLED PERSON’S NAME
Disabled person must be a Massachusetts resident. Please note the information required in this
application may affect your license status.
I hereby authorize the healthcare provider completing this form to discuss and release any or all medical records
pertaining to its content with or to representatives of the Registry of Motor Vehicles.
Signature of Disabled Person Date
Please Print Disabled Person’s Information
Last Name First Name MI
Address City/Town Zip Code
( )
Date of Birth Social Security Number Telephone Number
License Number Class Expiration Date Restrictions
Is this the first time you have submitted an application for disabled placard/plate? q Yes qNo
If applicable, please print your current disabled plate or placard number
I am applying for the following:
q Placard No fee required for a placard.
q Plate Only issued to individuals who have a vehicle registered in their name.
q DV Plate Only issued to individuals who have a vehicle registered in their name. You must submit
a letter from the Veteran’s Administration which states that your disability is at least 80
percent service connected.
Important Customer Information
Incomplete applications will not be processed. This application must be submitted within 30 days of the
healthcare provider's certification. You should allow for internal RMV processing time. Please note additional
documentation may be required.
FOR REGISTRY OF MOTOR VEHICLE USE ONLY
q Approved Date:_______________By:_______________
q Not Approved Date:_______________By:_______________ Reason Code:________
Comments:__________________________________________________________________________________
____________________________________________________________________________________________
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:
q Has been declared legally blind (please attach copy of certification). Applicants in this classification
must surrender their driver’s license.
q 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
2
. Applicants whose
O
2
saturation level is 88% or less, even with supplemental O
2
, MUST surrender their driver’s license.
q Uses portable oxygen.
q Has a Class III cardiac condition according to the standards set by the American Heart Association
(See Classification Guidelines).
q 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.
q Cannot walk 200 feet without stopping to rest. Please state clinical diagnosis and exact nature of
impairment:
q Cannot walk without the assistance of another person, prosthetic aid, or other assistive device.
Please state device used
and exact nature of impairment:
q 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?
qYes qNo
.
Please refer to attached guidelines
LENGTH OF DISABILITY
q Condition is permanent (in excess of two years)
q 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:
q The person applying for this permit is medically qualified to operate a motor vehicle safely.
q 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.
q 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.
Individual customers to whom the Registry issues “disabled” plates or placards must
understand their obligation to the entire disabled community. Allowing anyone else to
use the privileges that accompany these plates or placards is a citable offense which
may result in immediate revocation. More importantly, such abuses deny parking spaces
to those who are medically disabled.
By accepting one of these placards or plates, you accept the responsibility to use it for
its intended purpose. If you loan a placard to someone else, or allow another driver to
park your vehicle in a “handicapped” parking spot, you are denying your disabled
neighbors the access they need and deserve. Please respect the needs of others, and
make sure our friends and family members understand that mobility cannot be taken for
granted.
If you are granted the privilege of parking closer to your destination, don’t take the matter
lightly. Know the rules and obey them. With your cooperation, convenient parking spaces
for the disabled will always be available in the Commonwealth of Massachusetts.
Sincerely yours,
The Medical Affairs Branch
Commonwealth of Massachusetts,
Registry of Motor Vehicles
20060 Rev. 5/98
