Physicians Statement For Placard Form – Fill Out and Use This PDF

	MISSOURI DEPARTMENT OF REVENUE
	MOTOR VEHICLE BUREAU	FORM
	PO BOX 598, JEFFERSON CITY MO 65105-0598
	(573) 526-3669 www.dor.mo.gov/mvdl	1776
	PHYSICIAN’S STATEMENT FOR DISABLED
	LICENSE PLATES/PLACARD	(REV. 08-2010)

THIS STATEMENT IS ONLY VALID FOR 90 DAYS.

TO BE COMPLETED BY A AN ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN, CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST OR OPTOMETRIST. IF YOU HAVE QUESTIONS, CALL (573) 526-3669.

ATTENTION AN ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN, CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST OR OPTOMETRIST:

Missouri law requires this form to be completed for new applicants and every fourth year for renewal applicants to obtain disabled person license plates and/or placards. Section 301.142.1, RSMo, defines “physically disabled” as listed below. Please complete the form in full. At least one disability must be marked. You must personally sign this form. A stamped signature or signature of a nurse is NOT acceptable. Disabilities other than those listed below do not qualify the applicant for disabled person license plates and/or placards.

PATIENT’S NAME

PATIENT’S DLN OR FEIN

DATE OF BIRTH

GENDER

		_ _ / _ _ / _ _ _ _
PATIENT’S ADDRESS	CITY		STATE	ZIP CODE
CHECK ONE	PRINTED NAME OF PHYSICIAN/LICENSEE		PHYSICIAN’S TELEPHONE NO.
ADV PRAC REG NURSE
LICENSED PHYSICIAN
			(_ _ _) _ _ _ - _ _ _ _
CHIROPRACTOR
	LICENSE NUMBER		STATE OF LICENSE
PHYSICIAN’S ASSISTANT
PODIATRIST
OPTOMETRIST

CHECK 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.

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.

*A Temporary Placard is valid up to 180 days from the date of this statement. (See reverse for information)

PERSONAL SIGNATURE AND CERTIFICATION OF ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN, CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST, OR OPTOMETRIST IS REQUIRED. YOU MUST PERSONALLY SIGN THIS FORM. A STAMPED SIGNATURE OR A SIGNATURE OF A NURSE IS NOT ACCEPTABLE.

It is a class B misdemeanor for an advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist or optometrist to:

1.Issue, sign, or furnish a statement to any person who does not meet one or more of the conditions above; or

2.Issue, sign, or furnish a statement to any person for a condition above, the diagnosis of which is outside his or her scope of license.

A class B misdemeanor is punishable by a fine not to exceed $500 and/or imprisonment not to exceed 6 months.

I certify that I 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 and/or placards.

MO 860-0412 (08-2010)

SEE REVERSE FOR MORE INFORMATION

TEMPORARY PLACARD INFORMATION

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 (DOR-1776). If the temporary period of disability is not specified by an advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist or optometrist, a Temporary Placard will be issued only for a period of 30 days.

RESPONSIBILITIES OF ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN, CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST OR OPTOMETRIST

An advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist 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.

The medical or other records of the advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist or optometrist who issued and signed this form shall be open to inspection and review by such practitioner’s licensing board, in order to verify compliance. Information contained within such records shall be confidential unless required for prosecution, disciplinary purposes, or otherwise required to be disclosed by law.

MO 860-0412 (08-2010)