Form 1776 at a glance
What it is: Form 1776 is the Physician's Statement for Disabled License Plates or Placards.
Who signs: Personal signature of advance practice registered nurse, licensed physician, chiropractor, physician assistant, podiatrist, physical therapist, occupational therapist, or optometrist. A stamped signature or signature of a nurse is not acceptable.
Missouri law requires this form to be completed for new applicants and every eighth year for renewal applicants to obtain disabled person license plates or placards.
A filled-in Form 1776 example: a physician certifies a permanent disability
How to fill out Form 1776, box by box
Patient's Information
Under Patient's Information, enter the Name (Last, First, Middle), Driver License Number or Federal Employers I.D. Number, Date of Birth (MM/DD/YYYY) and Gender.
Enter the Street, Rural Route, or P.O. Box, City, State and Zip Code.
Physician's Information
Mark Adv. Practice Registered Nurse, Physician Assistant, Chiropractor, Physical Therapist, Occupational Therapist, Optometrist, Licensed Physician or Podiatrist.
Under Physician's Information, enter the Printed Name of Physician or Licensee, Physician's Phone Number, License Number and State of License.
Disability
Select each disability as defined in Section 301.142.1, RSMo that applies. A person's age shall not be a factor in determining a disability.
Please complete the form in full. At least one disability must be marked.
Disabilities other than those listed in the Disability section do not qualify the applicant for disabled person license plates or placards.
The person cannot ambulate or walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic condition, or other severe and disabling condition.
The person cannot ambulate or walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device.
The person is restricted by a respiratory or other disease to such an extent that the person's forced respiratory expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60 mm/hg on room air at rest.
The person uses portable oxygen.
The person has a cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV according to the standards set by the American Heart Association.
The person is blind as defined in Section 8.700, RSMo.
Permanent Disability or Temporary Disability
Mark Permanent Disability or Temporary Disability*. For Temporary Disability*, provide the Expiration Date (MM/DD/YYYY).
For Temporary Disability*, a date is required or the minimum of 30 days will be used. This date cannot exceed 180 days from the date of this statement. See reverse side for additional information.
If the temporary period of disability is not specified by an advance practice registered nurse, licensed physician, chiropractor, physician assistant, podiatrist, physical therapist, occupational therapist, or optometrist, a Temporary Placard will be issued only for a period of 30 days.
Upon expiration, a Temporary Placard may be renewed once for an additional 180 days, provided the applicant reapplies and submits a new Physician's Statement for Disabled License Plates and/or Placards (Form 1776).
Signature and Certification
By signing, the examiner certifies that they have physically examined the person listed above and determined he or she is physically disabled for the reason(s) indicated above as required by Section 301.142.1, RSMo in order to obtain disabled license plates or placards.
Enter the Date (MM/DD/YYYY).
It is a Class B misdemeanor for an advance practice registered nurse, licensed physician, chiropractor, physician assistant, podiatrist, physical therapist, occupational therapist, or optometrist to: 1. Issue, sign, or furnish a statement to any person who does not meet one or more of the conditions in the list of conditions on page 1; or 2. Issue, sign, or furnish a statement to any person for a condition in the list of conditions on page 1, the diagnosis of which is outside his or her scope of license.
More rules for Form 1776
An advance practice registered nurse, licensed physician, chiropractor, physician assistant, podiatrist, physical therapist, occupational therapist, or optometrist who issues and signs this form shall maintain a copy of this form in the disabled person's medical chart and maintain sufficient documentation as to objectively confirm that such a condition exists.
A chiropractor, podiatrist, or optometrist may only issue and sign this form for those conditions which he or she is legally authorized to diagnose and treat.
Common questions about Form 1776
Is there a deadline?
This statement is only valid for 90 days.
Is there a penalty?
A Class B misdemeanor is punishable by a fine not to exceed $500 or imprisonment not to exceed 6 months (checked October 20, 2026).
Sources
[1] Form 1776, Physician's Statement for Disabled License Plates or Placards, Missouri Department of Revenue (the Official source link on this page).