Vsa 54 Form PDF Details

For veterans living with disabilities, the VSA 54 form represents a critical pathway to acknowledging and certifying their conditions under the provisions of Virginia law, thereby unlocking several benefits tailored to accommodate their needs. Introduced on July 1, 2007, its primary purpose is to enable veterans to certify a qualifying disability, which in turn allows them to apply for a registration fee exemption and special license plates, including those displaying the international symbol of access. The form must first be validated by a Veterans Services Officer and then submitted alongside a registration application to the DMV. It calls for detailed veteran applicant information, including the Veterans Administration claim number and an option to request disabled veteran (DV) plates. The certification process involves a medical professional—be it a physician, physician's assistant, or nurse practitioner—confirming the veteran's disability, outlining specific conditions such as loss of sight or limb, severe mobility restrictions, respiratory or cardiac conditions, arthritic, neurological, orthopedic limitations, mental or developmental impairments, including autism spectrum disorders, Alzheimer's disease, other dementias, or legal blindness. Chiropractors and podiatrists can also certify conditions primarily affecting the ability to walk. This thorough process highlights the comprehensive approach taken to ensure that veterans receive the recognition and support they require, emphasizing the sacrifice they have made and the particular challenges they may face as a result of their service.

QuestionAnswer
Form NameVsa 54 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesvsa 54 form, yyyy, spirometry, VSA

Form Preview Example

VETERAN

CERTIFICATE OF DISABILITY

VSA 54 (07/01/2007)

Purpose: Veterans use this form to certify to a qualifying disability and to apply for registration fee exemption and special license plates.

Instructions: Send the completed form for validation to Veterans Services Officer, 210 Franklin Road, S.W.

Roanoke, VA. 24011. Submit validated form and your registration application to DMV at the address above.

VETERAN APPLICANT INFORMATION

DISABLED VETERAN NAME

VETERANS ADMINISTRATION CLAIM NUMBER

CHECK THIS BOX TO REQUEST DISABLED VETERAN (DV) PLATES DISPLAYING THE INTERNATIONAL SYMBOL OF ACCESS (DISABLED SYMBOL). MEDICAL PROFESSIONAL CERTIFICATION IS REQUIRED BELOW.

VETERANS ADMINISTRATION USE ONLY

THIS VETERAN IS CERTIFIED DISABLED AS FOLLOWS UNDER PROVISIONS OF VIRGINIA LAW

 

 

Loss of sight, limb(s) or hand(s)

 

Loss of use of limb(s) or hand(s)

 

 

100% permanently and totally disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VETERANS SERVICES OFFICER NAME

 

 

 

VETERANS SERVICES OFFICER SIGNATURE

 

 

 

 

 

 

 

 

 

PHYSICIAN, PHYSICIAN'S ASSISTANT, NURSE PRACTITIONER CERTIFICATION

This certification may be completed and signed by a Veteran Services physician or the applicant's choice of physician, physician's assistant, nurse practitioner.

Cannot walk 200 feet without stopping to rest.

Uses portable oxygen.

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.

Has a cardiac condition to the exent that functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association.

Is restricted by lung disease to such an extent that 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 millimeters of mercury on room air at rest.

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

Has been diagnosed with a mental or developmental amentia or delay that impairs judgment including, but not limited to, an autism spectrum disorder.

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

Is legally blind or deaf.

Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)

Other condition that creates a safety concern while walking because of impaired judgment or other physical, developmental or mental limitation. SPECIFY CONDITION (required)

CHIROPRACTOR, PODIATRIST CERTIFICATION

This certification may be completed and signed by the applicant's choice of chiropractor or podiatrist.

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.

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

Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)

MEDICAL PROFESSIONAL CERTIFICATION STATEMENT

I certify and affirm that the veteran applicant has a PERMANENT DISABILITY which limits or impairs his/her ability to walk due to the reason indicated above.

MEDICAL PROFESSIONAL NAME (print )

MEDICAL LICENSE NUMBER

ISSUING STATE

 

 

EXPIRATION DATE (mm/dd/yyyy)

MEDICAL PROFESSIONAL SIGNATURE

DATE (mm/dd/yyyy)

OFFICE TELEPHONE NUMBER

( )

OFFICE FAX NUMBER

( )

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vsa 54 writing process detailed (portion 2)

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