The Massachusetts Disabled Parking App form is a crucial document for individuals seeking a disabled parking placard or plate. This application must be completed by the disabled person and their healthcare provider, ensuring that all required information is accurately submitted. To begin the process, fill out the form by clicking the button below.
The Massachusetts Disabled Parking Application form is a crucial document designed to help individuals with disabilities obtain the necessary parking privileges they need for mobility. This application must be completed in the name of the disabled person and requires the involvement of a healthcare provider to certify the applicant's medical condition. Sections A, B, and C focus on the disabled applicant's personal information, including their name, date of birth, and Social Security number, as well as the type of service requested—whether a placard, plate, or motorcycle plate. The healthcare provider's sections D and E include essential medical qualifications and certifications, ensuring that the application is thorough and accurate. It's important to note that incomplete applications will be returned, which can delay the process. Additionally, the form outlines legal responsibilities and potential penalties for misuse, emphasizing the importance of adhering to the rules. All applications must be submitted to Medical Affairs within thirty days of certification, and applicants should be prepared to provide any additional documentation if required. Overall, this form is a vital step in ensuring that those with disabilities can access the parking accommodations they need to navigate their communities effectively.
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)
Email
Phone Type
Phone #
Cell
Home Work
Emergency Contact Information: (optional)
Name
Cell Home Work
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
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
NPI #
Board of Registration in Medicine #
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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Filling out the Massachusetts Disabled Parking Application form is a straightforward process, but it requires careful attention to detail. Make sure to complete all sections accurately to avoid delays. Both the disabled individual and their healthcare provider must provide signatures. Once completed, the application should be sent to the specified address within the required timeframe.
The Massachusetts Disabled Parking App form is designed to allow individuals with disabilities to apply for a disabled parking placard or plate. This form ensures that those who need accessible parking can obtain the necessary permits to park in designated spaces. It is important for applicants to provide accurate information to facilitate the approval process.
Both the disabled person and their healthcare provider must sign and date the application. The disabled person provides their personal information, while the healthcare provider certifies the medical condition that qualifies the individual for disabled parking privileges. This dual signature requirement helps ensure the integrity of the application.
If the application is incomplete, it will not be processed and will be returned to the applicant. To avoid delays, it is crucial to fill out all sections of the form accurately. Each required field must be completed to ensure that the application can be reviewed and approved in a timely manner.
The completed application must be submitted to Medical Affairs within thirty (30) days of the healthcare provider's certification. Timely submission is essential to prevent any complications or delays in receiving your disabled parking placard or plate.
No, RMV Service Center locations do not process disability parking applications. If you drop off your application at a service center, it may add to the processing time. It is best to mail the application directly to Medical Affairs to ensure prompt handling.
There are several types of permits available:
If your medical condition changes, it is important to notify the RMV. Depending on the nature of the change, you may need to reapply or update your information. Keeping your application current ensures compliance with the rules governing disabled parking privileges and helps avoid any potential legal issues.
Incomplete Information: Many applicants fail to fill out all required fields in sections A, B, and C. Missing information can lead to delays or rejection of the application.
Incorrect Signatures: Both the disabled person and the healthcare provider must sign and date the application. Omitting either signature will result in the application being returned.
Submission Timing: Applicants sometimes submit the application more than thirty days after the healthcare provider’s certification. This can lead to automatic rejection.
Wrong Submission Location: Some individuals mistakenly drop off their applications at RMV Service Centers. These locations do not process disability parking applications, which can cause unnecessary delays.
Failure to Provide Additional Documentation: Applicants may overlook the need for extra documentation. This could include medical records or specific certifications required for certain types of plates.
Misunderstanding the Rules: Some applicants do not fully read or understand the rules regarding the use of the placard or plate. Misuse can lead to serious penalties, including fines and loss of privileges.
The Massachusetts Disabled Parking App form is essential for individuals seeking disabled parking privileges. Along with this application, there are several other documents that may be required or beneficial during the application process. Here’s a brief overview of these forms and documents:
Having these documents ready can streamline the application process for disabled parking in Massachusetts. Ensure that all information is accurate and complete to avoid delays or complications.
The Massachusetts Disabled Parking Application form shares similarities with the application for a state-issued identification card. Both documents require personal information, including the applicant's name, address, and date of birth. Additionally, both forms necessitate verification of the applicant's identity and residency. Just as the disabled parking application must be signed by a healthcare provider, the identification card application may also require a signature from a guardian or authorized individual, particularly for minors or individuals with disabilities. The submission process for both applications typically involves mailing the completed forms to a designated state office.
Another document akin to the Massachusetts Disabled Parking Application is the application for a handicap accessible vehicle registration. Like the parking application, this document requires detailed personal information about the applicant, including their medical condition and the need for specialized vehicle modifications. Both applications involve a healthcare provider's certification, affirming the applicant's eligibility based on their disability. Furthermore, both applications aim to ensure that individuals with disabilities have access to necessary accommodations, whether it be parking or vehicle accessibility.
The application for a veteran's disability benefit also bears resemblance to the Massachusetts Disabled Parking Application. Both forms require the applicant to provide personal information and a detailed account of their medical condition. In the case of veteran benefits, documentation of service-related disabilities is necessary, similar to how the disabled parking application requires a healthcare provider's certification. Both processes are designed to support individuals with disabilities, ensuring they receive appropriate benefits or accommodations based on their unique circumstances.
The Social Security Administration's application for disability benefits shares common elements with the Massachusetts Disabled Parking Application. Both documents require comprehensive personal information and medical documentation to establish eligibility. The healthcare provider's role is crucial in both applications, as they must certify the applicant's condition. Furthermore, both applications are time-sensitive, requiring prompt submission to avoid delays in receiving benefits or accommodations.
The application for a medical marijuana card in Massachusetts has similarities to the disabled parking application in that both require a medical professional's recommendation. Applicants must provide personal information and details about their medical condition. The healthcare provider's signature is essential in both cases to validate the applicant's need for the respective accommodations. Additionally, both applications aim to enhance the quality of life for individuals with disabilities or medical conditions, ensuring they have access to necessary resources.
The application for a special education eligibility evaluation mirrors the Massachusetts Disabled Parking Application in that both require detailed information about the individual's condition. In the case of special education, documentation from educators and healthcare providers is necessary to assess eligibility. Both processes involve a thorough review to determine the appropriate accommodations or services needed to support the individual. The collaborative nature of both applications emphasizes the importance of a team approach in addressing the needs of individuals with disabilities.
The process for applying for a disability insurance claim is similar to the Massachusetts Disabled Parking Application in that both require comprehensive documentation of the applicant's medical condition. In both cases, the involvement of healthcare providers is critical, as they must provide evidence of the individual's disability. Both applications also have implications for the applicant's financial well-being, as they seek to secure necessary support or benefits based on their circumstances.
Finally, the application for a public assistance program, such as Supplemental Nutrition Assistance Program (SNAP), shares similarities with the Massachusetts Disabled Parking Application. Both forms require personal information and documentation of the applicant's situation. In SNAP applications, proof of income and residency is necessary, while the disabled parking application requires medical documentation. Both processes aim to provide assistance to individuals in need, ensuring they have access to essential resources and support.
When filling out the Massachusetts Disabled Parking Application form, it is essential to follow specific guidelines to ensure a smooth process. Below is a list of things you should and should not do:
This is not true. RMV Service Centers do not process disability parking applications. Submitting your application at a service center may actually delay the processing time.
Both the disabled person and the healthcare provider must sign and date the application. Missing signatures will lead to delays.
A healthcare provider must complete specific sections of the application. Their certification is essential for approval.
This is illegal. Allowing someone else to use your placard without you present can lead to hefty fines and loss of privileges.
Key Takeaways for Filling Out the Massachusetts Disabled Parking App Form: