Dmv Form Med 10 PDF Details

Providing accessible parking options to individuals with disabilities is a fundamental aspect of fostering inclusivity and accessibility in public spaces. The DMV Med 10 form serves as a critical tool in this endeavor, enabling persons with disabilities to apply for disabled parking placards or license plates. Taking effect from July 1, 2020, this form not only standardizes the application process but also specifies the conditions under which eligibility is determined and the types of parking aids available. Applicants are required to furnish detailed personal information, undergo a certification process by a licensed medical professional, and choose between a placard or license plate, depending on their needs or the nature of their disability. Importantly, the form highlights that the misuse of issued placards or plates, including lending them to others, may result in significant penalties, underscoring the legal and ethical responsibilities that come with the issuance of such parking aids. To streamline the process, the form outlines how to apply for replacements in case of loss, theft, or damage and delineates the fees associated with each application type. By providing a structured way to apply for and renew disabled parking permits, the DMV Med 10 form plays a pivotal role in ensuring equal access and convenience for individuals with disabilities, thus contributing to their autonomy and mobility.

QuestionAnswer
Form NameDmv Form Med 10
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvirginia disabled parking, dmv handicap form, dmv disability form, disabled parking placard application

Form Preview Example

DISABLED PARKING PLACARD

OR LICENSE PLATES

APPLICATION

MED 10 (07/01/2020)

Purpose: Persons with disabilities use this form to apply for a disabled parking placard or disabled parking license plates.

Instructions: For a parking placard OR replacement placard ID card, submit this form with applicable fees. Placard or replacement ID card will be mailed to you within approximately 15 days. Only one placard may be issued to a customer.

For disabled parking license plates, submit this form, a completed License Plate Application (VSA 10) and applicable fees.

For placard and/or license plates, submit forms and fees to any Customer Service Center, DMV Select or mail to DMV, Data Integrity, P.O. Box 85815, Richmond, VA 23285-5815.

APPLICANT INFORMATION (person with disability)

FULL LEGAL NAME (last) (first) (middle) (suffix)

DMV ASSIGNED NUMBER OR SOCIAL SECURITY NUMBER

NOTE: If you enter a residence or mailing address that is other than what is currently on DMV's system, complete an "Address Change Request" (ISD 01).

CURRENT RESIDENCE ADDRESS

 

 

 

CITY

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

CITY OR COUNTY OF RESIDENCE

 

 

 

 

 

 

 

DAYTIME TELEPHONE NUMBER OR CELL PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (if different from above)

CITY

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

BIRTH DATE (mm/dd/yyyy)

 

HAIR COLOR

 

EYE COLOR

 

HEIGHT

 

 

WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FT

IN

 

 

LBS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION TYPE

 

 

 

 

 

 

 

ORIGINAL APPLICATION: (check applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISABLED PARKING PLACARD

 

 

DISABLED PARKING LICENSE PLATE

* Only permanently disabled persons or institutions that transport

 

 

 

 

 

 

$5.00 fee (INCLUDES ID CARD)

 

 

(complete form VSA 10)*

 

individuals with disabilities may obtain disabled license plates.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FOR REPLACEMENT: (check applicable)

 

 

 

 

 

REASON FOR REPLACEMENT - original was:

 

 

DISABLED PARKING PLACARD

 

 

DISABLED PLACARD ID CARD ONLY

DISABLED LICENSE PLATE

 

 

 

Lost

 

 

 

 

Stolen

 

 

 

 

 

 

 

 

 

 

 

 

 

$5.00 fee (INCLUDES ID CARD)

 

 

$2.00 fee

 

 

 

$10.00 fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Destroyed/Mutilated

 

 

Never Received

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISABLED PARKING LICENSE PLATES (HP) (check one)

The vehicle on which HP plates will be used is specifically equipped and used for transporting groups of physically disabled persons. I am the vehicle owner and the parent/legal guardian of a disabled dependent(s). List the name of each disabled person below.

APPLICANT CERTIFICATION (person with disability)

I understand that misuse, counterfeiting, or alteration of disabled placards may result in fines up to $1000.00 and up to 6 months in jail

and/or revocation of disabled parking privileges. I certify that I have a (check one): Temporary Permanent disability that limits or impairs my ability to walk or creates a safety concern while walking.

I also understand that the disabled parking placard or plates issued to me cannot be loaned to anyone, including family members or friends, to benefit a person other than myself.

I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.

APPLICANT SIGNATURE

DATE (mm/dd/yyyy)

DMV USE ONLY

TEMPORARY PLACARD (up to 6 months)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORIGINAL

 

 

REISSUE

 

Replacement

 

 

 

 

 

Placard

 

 

Placard ID

 

 

License Plate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lost

 

 

 

 

Stolen

 

 

Destroyed/Mutilated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERMANENT PLACARD (5 years)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORIGINAL

 

 

 

 

 

 

 

 

 

 

REISSUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Medical professional certification required.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Replacement

 

 

 

 

 

 

 

 

 

 

 

 

RENEWAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Placard

 

 

 

Placard ID

 

 

License Plate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(No medical professional certification required.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lost

 

 

 

 

Stolen

 

 

Destroyed/Mutilated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HP PLATES

 

ORIGINAL PLATES

DUPLICATE PLATES

 

 

REISSUE PLATES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

submit completed

 

Lost

 

 

 

 

 

 

 

 

Unreadable (letters/numbers unclear)

 

 

 

 

form VSA 10

 

Destroyed

 

 

 

 

 

 

 

 

Plates never received

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15-DAY PLACARD RECEIPT NUMBER

PLACARD EXPIRATION DATE (mm/dd/yyyy)

EMPLOYEE STAMP

Is severely limited in ability to walk due to an arthritic, neurological or orthopedic condition.

The front of this form must be completed before the medical professional signs the certification.

MED 10 (07/01/2020) page 2

APPLICANT FULL LEGAL NAME (last, first, middle, suffix)

NOTE: (This page does not have to be completed to renew permanent placards.)

DISABILITY TYPE

Temporarily limited or impaired beginning date (mm/dd/yyyy) _____________ and ending date (mm/dd/yyyy)_________________(not to

exceed 6 months).

Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs movement from one place to another or the ability to walk as defined in Virginia Code §46.2-1240, and that has reached the maximum level of improvement and is not expected to change even with additional treatment.

LICENSED PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CERTIFICATION

Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (check below)

 

Cannot walk 200 feet without stopping to rest.

 

Is restricted by lung disease to such an extent that forced

 

Uses portable oxygen.

 

(respiratory) expiratory volume for one second, when measured by

 

 

 

 

 

spirometry, is less than one liter, or the arterial oxygen tension is

 

Cannot walk without the use of or assistance from any of the following:

 

 

 

 

less than 60 millimeters of mercury on room air at rest.

 

another person, brace, cane, crutch, prosthetic device, wheelchair, or

 

 

 

 

Has been diagnosed with a mental or developmental amentia or

 

 

 

other assistive device.

 

 

 

delay that impairs judgment including, but not limited to, an autism

 

 

 

Has a cardiac condition to the extent that functional limitations are

 

 

 

 

spectrum disorder.

 

classified in severity as Class III or Class IV according to standards set

 

 

 

Has been diagnosed with Alzheimer's disease or another form of

 

 

 

by the American Heart Association.

 

 

 

dementia.

 

 

 

 

Is severely limited in ability to walk due to an arthritic, neurological, or

 

Is legally blind or deaf.

 

 

 

orthopedic condition.

 

 

 

 

Other condition that limits or impairs the ability to walk, or creates a safety concern while walking because of impaired judgement or other physical, developmental, or mental limitation (Specific condition description must be specified below).

LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION

Reason this patient's ability to walk is limited or impaired. (check below)

Cannot walk 200 feet without stopping to rest.

Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.

Other condition that limits or impairs the ability to walk (Specific condition description must be specified below).

LICENSED MEDICAL PROFESSIONAL CERTIFICATION

I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety concern while walking as described above.

I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.

 

Physician

 

Physician Assistant

 

Nurse Practitioner

 

Chiropractor

 

Podiatrist

MEDICAL PROFESSIONAL NAME (print)

OFFICE TELEPHONE NUMBER

OFFICE FAX NUMBER

LICENSE TYPE

LICENSE NUMBER

STATE ISSUING LICENSE (required) LICENSE EXPIRATION DATE (required)

MEDICAL PROFESSIONAL SIGNATURE

DATE (mm/dd/yyyy)

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1. Fill out your handicap placard virginia with a group of essential fields. Collect all the important information and be sure not a single thing omitted!

Part number 1 in completing dmv handicap parking permit application form

2. Soon after filling out this part, go to the next step and enter all required details in all these blanks - I am the vehicle owner and the, APPLICANT CERTIFICATION person, I understand that misuse, DATE mmddyyyy, Temporary, Permanent, TEMPORARY PLACARD up to months, DAY PLACARD RECEIPT NUMBER, ORIGINAL, REISSUE, Replacement, Placard, Placard ID, License Plate, and Lost.

DATE mmddyyyy, Placard, and REISSUE of dmv handicap parking permit application form

You can easily make a mistake while completing your DATE mmddyyyy, for that reason make sure to reread it prior to when you send it in.

3. Within this stage, look at The front of this form must be, APPLICANT FULL LEGAL NAME last, NOTE This page does not have to be, DISABILITY TYPE, Temporarily limited or impaired, Permanently limited or impaired A, LICENSED PHYSICIANPHYSICIAN, Reason this patients ability to, Cannot walk feet without stopping, Uses portable oxygen Cannot walk, Is restricted by lung disease to, Is severely limited in ability to, Is legally blind or deaf, and Other condition that limits or. Each of these need to be filled out with highest precision.

dmv handicap parking permit application form writing process explained (part 3)

4. This specific part comes next with the next few form blanks to fill out: LICENSED CHIROPRACTOR OR, Reason this patients ability to, Cannot walk feet without stopping, Cannot walk without the use of or, Is severely limited in ability to, Other condition that limits or, LICENSED MEDICAL PROFESSIONAL, I certify and affirm that the, I further certify and affirm that, Physician, Physician Assistant, Nurse Practitioner, Chiropractor, Podiatrist, and MEDICAL PROFESSIONAL NAME print.

Step no. 4 of filling in dmv handicap parking permit application form

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