Bfs 108 Form PDF Details

Navigating the complexities of disability parking can be overwhelming, but thankfully, resources like the BFS-108 form from the Michigan Department of State aim to streamline the process. This comprehensive application facilitates individuals and organizations in their quest to obtain the necessary parking placards for easier access to public and private venues. Applicants must provide detailed information, including personal details and a medical certification from a licensed professional such as a physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant, affirming their mobility challenges. For individuals, a critical aspect of this form is the dual-purpose function that not only helps in acquiring a disability parking placard but also may qualify them for free parking under certain conditions, assessed on a set of stringent medical criteria. Additionally, organizations looking to secure parking placards for transporting disabled persons are required to navigate Part 4 of the application, emphasizing the form’s broader scope in accommodating a variety of needs. With strict penalties for misuse or fraudulent claims, the importance of accuracy and honesty throughout the application process cannot be overstated. Understanding the BFS-108 form is the first step in ensuring those with disabilities can secure the parking privileges necessary for enhancing their mobility and quality of life.

QuestionAnswer
Form NameBfs 108 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshandicapped parking placard application, state of michigan handicap parking permit, state of michigan handicap, handicap parking permit michigan

Form Preview Example

Placard Number:

MICHIGAN DEPARTMENT OF STATE

 

Disability Parking Placard Application

Office Use Only:

 

Expiration

 

Date:

Directions:

Applicants please complete and sign Part 1. Your physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant must complete Part 2 and the certification on the bottom of this page. If you also qualify for free parking, your physician, chiropractor, optometrist, nurse practitioner, physician’s assistant, or

physical therapist must also complete Part 3. Organizations applying for parking placards to provide transportation services for disabled persons complete Part 4. Completed applications may be presented at any Secretary of State branch office or mailed to the address on the reverse side of this form. (Application cannot be processed without signed release of information and physician’s certification.)

Part 1: Release of Information and Signature

I am applying for a disability parking placard as provided in Public Act 300 of 1949. I authorize the release of the medical information described below to the Michigan Department of State. I certify the information is true and realize by making a false statement on this application I am subject to the penalties described on the reverse side of this form.

(Please print)

Name

(First, Middle, Last)

 

Date of Birth

Michigan Drivers License or ID Card #

 

 

 

 

 

 

Street Address

 

City

State

Zip

 

 

 

 

 

 

County

 

Daytime Phone Number

Last Parking Permit Number

Are you a Michigan resident?

 

 

(

)

 

YES §

NO §

Signature of Disabled Person

 

Today’s Date

 

 

X

 

 

 

 

 

 

Signature of Representative (If presented by representative)

 

Representative’s Driver License Number

X

 

 

 

 

 

 

Part 2: Medical Eligibility Standards and Physician’s Determination

The Michigan Vehicle Code [MCL 257.19a] states that a disabled person be determined by a licensed physician, physician’s assistant, chiropractor, nurse practitioner, physical therapist, or optometrist identifying one or more of the following characteristics which affect your patient’s ability to walk.

Circle all letters that apply

Right Eye:

Left Eye:

Both Eyes:

Visual field (in degrees):

a) Blindness. Corrected acuity level:

20/______

20/______

20/______

____________

b)An inability to walk more than 200 feet without having to stop and rest. Please provide the diagnosis for this ambulatory disability: _______________________________________________________________________________________

c)Patient must use a wheelchair, walker, crutch, brace, or other ambulatory aid to walk.

Describe: _______________________________________________________________________________________

d)Patient has a lung disease from which the forced expiratory volume for one second, when measured by spirometry, is less than one liter, or from which the arterial oxygen tension is less than 60mm/hg of room air at rest.

e)Patient has a cardiovascular condition which measures between 3 and 4 on the New York Heart Classification Scale, or which renders the patient incapable of meeting a minimum standard for cardiovascular health established by the American Heart Association and approved by the Michigan Department of Public Health.

f)Patient has an arthritic, neurological, or orthopedic condition that severely limits ability to walk.

Describe: _______________________________________________________________________________________

g)Patient has a persistent reliance upon an oxygen source other than ordinary air.

Physician’s Certification

A parking placard will be issued solely on the physician’s evaluation

 

 

 

 

 

 

 

 

 

 

Patient’s condition is: Permanent

§

Temporary

§

If temporary, estimated duration: ______months (maximum 6 months)

 

 

 

 

 

 

Physician’s Name

Medical Specialty

Office Telephone

Street Address

City, State, Zip

Office Fax

I certify the person listed above is eligible for a disability placard as provided in Public Act 300 of 1949. I also understand that making a false statement to obtain a disability parking placard is a misdemeanor and may result in fines, imprisonment, or both.

Physician’s Signature

X

Medical License Number *

Date

(Physician / Chiropractor / Physician’s Assistant / Optometrist / Nurse Practitioner / Physical Therapist)

*If the medical license was issued in a state other than Michigan, the physician must submit a copy of their medical license.

BFS-108 (06/18) NOTE: If the individual listed above is also eligible for free parking, Part 3 on the reverse side of this application must also be completed.

Part 3: Free Parking Application And Physician’s Certification

(Complete Parts 1, 2, and 3)

The free parking application is completed only when the applicant qualifies for free parking. To qualify, your patient must be a Michigan licensed driver, have an ambulatory disability described in Part 2, and also have one of the following conditions. Economic need is not a consideration.

Circle all letters that apply:

a)The patient cannot insert coins or tokens in a parking meter or cannot accept a ticket from a parking lot machine due to a lack of fine motor control of both hands.

b)The patient cannot reach above their head to a height of 42 inches from the ground, due to a lack of finger, hand, or upper extremity strength or mobility.

c)The patient cannot approach a parking meter due to use of a wheelchair or other ambulatory device.

d)The patient cannot walk more than twenty feet due to an orthopedic, cardiovascular, or lung condition in which the degree of debilitation is so severe that it almost completely impedes the patient’s ability to walk. (A condition requiring applicant to rest after walking twenty feet when not using a wheelchair or other ambulatory device.)

I certify the person listed on the front of this application is also eligible for free parking as provided in state law [MCL 257.675]. I under- stand that making a false statement to obtain a free parking sticker is a misdemeanor and may result in fines, imprisonment, or both.

Physician’s signature: XDate

(Physician / Chiropractor / Physician’s Assistant / Optometrist / Nurse Practitioner / Physical Therapist)

_________________________________________________________________________________________________

Part 4: Organization Request For Disability Parking Placards (Please print)

Name of Organization

 

County

Telephone Number

 

 

 

(

)

 

 

 

 

 

Street Address

City, State, Zip

 

 

 

 

 

 

Describe the transportation services your organization provides to persons with disabilities:

 

 

Number of disability placards you are requesting: ________ (No more then 1 per vehicle used to transport clients.)

I am applying for a disability parking placard as provided in Public Act 300 of 1949 and certify the above information is true.

Signature of Organization Officer

Printed Name of Organization Officer

Date

X

 

 

Organization Officer’s Driver License Number

Position (Title) with Organization

 

 

 

 

Note: If the organization ceases to provide specialized services to disabled persons, the parking placard must be returned to the Secretary of State for cancellation.

__________________________________________________________________________________________________

Penalties

Michigan Vehicle Code Section 257.676 Prohibits:

Using a disability parking placard to park in a designated parking space unless the disabled person is driving or being transported.

Altering, modifying, or selling a disability parking placard or free parking sticker.

Copying or forging, or using a copied or forged disability parking placard or free parking sticker.

Making a false statement to obtain a disability parking placard or free parking sticker, or committing a deception or fraud on a medical statement attesting to a disability.

Knowingly using or displaying a disability parking placard that has been canceled by the Secretary of State.

A violation is a misdemeanor and punishable by a fine up to $500 or imprisonment for up to 30 days, or both. A law enforcement officer may immediately confiscate a disability parking placard for improper use.

__________________________________________________________________________________________________

Return completed applications to any

Michigan Department of State

Secretary of State branch office or mail to:

Special Services Branch

 

PO Box 30764

 

Lansing, MI 48918

If you have any questions regarding disability parking placards, please call the Department’s Information Center at 1-888-767-6424.

Authority granted under Pubic Act 300 of 1949, as amended.

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