Massachusetts Disabled Parking App PDF Details

The Massachusetts Disabled Parking App Form is now available for download on the Commonwealth of Massachusetts website. The form, which is in PDF format, can be used to apply for a disabled parking placard or special license plate. The app is easy to use and can be filled out on your computer or mobile device. For more information on how to apply for a disability parking permit, please visit the MassDOT website.

You may find details about the type of form you need to submit in the table. It can show you just how long it will require to finish massachusetts disabled parking app, exactly what parts you need to fill in, etc.

QuestionAnswer
Form NameMassachusetts Disabled Parking App
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow to application disabled, disabled plate, massachusetts parking placard, placard

Form Preview Example

Application for Disabled Parking Placard/Plate

Mail to: Medical Affairs, PO Box 55889, Boston, MA 02205-5889 ● 857-368-8020 ● mass.gov/rmv

This side of application must be completed in the disabled person’s name.

Please note the information required in this application may affect your driver’s license.

•Incomplete application will not be processed and will be returned.

•Both disabled person and healthcare provider must sign and date this application. The disabled person’s information must be provided in sections A, B, and C. The healthcare provider must complete sections D and E.

•This application must be submitted to Medical Affairs within thirty (30) days of the healthcare provider’s certification.

•RMV Service Center locations do not process disability parking applications; dropping off at a service center location may add processing time.

•Additional documentation may be required.

A. Disabled Applicant Information – All fields must be completed

Last Name

 

 

First Name

 

 

 

Middle Name

 

Suffix

 

 

 

 

 

 

 

 

 

Date of Birth (MM/DD/YYYY)

Current Massachusetts Learner’s Permit, Driver’s

Gender

 

What is your Social Security Number?

 

 

License # (if applicable) or MA ID

 

M F X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address (Where you

actually reside)

 

 

 

 

 

 

 

Street (including #)

 

Apt. #

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Mailing Address

(same as above)

 

 

 

 

 

 

 

Street (including #)

 

Apt. #

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

Email

 

 

 

 

 

Phone Type

Phone #

 

 

 

 

 

 

Cell

Home Work

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Contact Information: (optional)

Email

Name

Phone Type

Cell Home Work

Phone #

B. Service Type

Type: Placard

No fee required for a placard. Disabled person is not required to have a vehicle registered in his/her name.

Plate

Only issued to individual who is primary owner with vehicle registered in his/her name. Registration fees apply.

Motorcycle Plate

Only issued to individual who is primary owner with vehicle registered in his/her name. Registration fees apply.

DV Plate

Only issued to individual who: a) is primary owner with vehicle registered in his/her name; b) provide the DV

 

(Disabled Veteran) Plate Letter from the Veteran’s Administration listing service-connected disabilities and total

 

combined rating; c) has qualifying conditions which meet Medical Affairs guidelines and total at least 60% of the

 

service-connected disability.

C. Certification and Signature of Applicant

Rules:

•It is illegal to allow someone to use your placard if you are not in the vehicle.

•It is illegal for an individual to have more than one placard (temporary or permanent).

•It is illegal to provide false information (persons can be prosecuted under Massachusetts Law).

•It is illegal to possess or display a counterfeit placard (altered or photocopied).

•It is illegal to forge a healthcare provider’s signature.

Acknowledgment:

•I have read the rules.

•I understand misuse of disabled parking may result in high motor vehicle citation fines ($500, first offense), license suspension terms, and the revocation of my disabled parking privileges.

•I certify under the penalty of perjury that all the information provided in this application, including the representation of my medical status/condition, is true and correct to the best of my knowledge.

•AUTHORIZATION TO RELEASE MEDICAL RECORDS – 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 RMV.

•For applicants for Disabled Veteran plates, I hereby authorize the Veteran’s Administration to release medical information concerning my service connected disability rating(s).

I have reviewed this completed Application Form and swear (affirm), under the penalties of perjury, that the information I have provided is true and complete.

I am aware that false statements are punishable by fine, imprisonment, or both under M.G.L. Chapter 90, Section 24B.

Signature of Disabled Person: ____________________________________________________ Date:__________________________

Applicant’s Name/Patient’s Name

Last 4 Digits of Social Security #

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MAB100_0821

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)

 

 

Provider’s First Name

 

 

 

 

 

 

 

 

Provider’s Address

 

 

 

 

 

 

Street

 

Apt. #

City

 

State

Zip Code

NPI #

 

Board of Registration in Medicine #

 

Phone #

 

 

 

 

 

 

I am a: Medical Doctor

Chiropractor Registered Nurse

Physician Assistant Osteopath Optometrist (legal blindness only)

Podiatrist

 

 

 

 

 

 

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: _______________________

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MAB100_0821

How to Edit Massachusetts Disabled Parking App Online for Free

You can fill out the application plate file with our PDF editor. The next actions may help you immediately get your document ready.

Step 1: To get started, click the orange button "Get Form Now".

Step 2: So you should be on the document edit page. It's possible to add, alter, highlight, check, cross, insert or remove areas or text.

Enter the required material in every segment to fill in the PDF application plate

disabled parking app fields to complete

You need to provide your data within the area I have reviewed this completed, Signature of Disabled Person Date, Applicants NamePatients Name, Last Digits of Social Security, and MAB.

step 2 to completing disabled parking app

Note down the expected information when you're within the Physician must complete the first, This application is completed for, Clinical Diagnosis Required NO, Duration of placard to be issued, If temporary please estimate, Please check ALL that apply, Unable to walk feet without, Legally Blind Certificate of, Chronic Lung Disease To such an, measured by spirometry is less, FEV test result O saturation, and NOTE Asthma alone is not a area.

step 3 to filling out disabled parking app

The field Cardiovascular Disease, AHA Functional Classification, Loss of Limb or permanent loss of, E Healthcare Provider, Providers First Name, Providers Address, Street NPI, Apt, City, State, Zip Code, Board of Registration in Medicine, Phone, I am a Medical Doctor, and Podiatrist will be where you can insert each side's rights and responsibilities.

Entering details in disabled parking app part 4

Step 3: Once you have selected the Done button, your document should be accessible for export to every electronic device or email address you indicate.

Step 4: Prepare duplicates of the form. This may save you from potential future issues. We don't read or share your data, therefore feel comfortable knowing it's going to be protected.

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