TemplatesOwl
Homepage ↦ Fill Out Your Massachusetts Disabled Parking App Form
Article Structure

The Massachusetts Disabled Parking App form is an essential document designed to facilitate access to disabled parking placards and plates for eligible individuals. This form must be filled out in the name of the disabled person seeking the benefits, and it requires multiple sections to be completed. Information such as personal details—including name, address, date of birth, and Social Security number—needs to be accurately entered. Equally important is the involvement of a healthcare provider, who must certify the applicant's medical condition by filling out specific sections of the form. This certification confirms that the applicant has a qualifying condition that impairs their ability to walk or operate a vehicle safely. It is crucial to note that the form mandates signatures from both the disabled individual and the healthcare provider, ensuring that all provided information is verified. Applications must be submitted within thirty days of certification to avoid delays, and incomplete submissions will be returned. Furthermore, applicants have to indicate their specific service type, whether they are applying for a placard, plate, or a motorcycle plate. Acknowledgment of regulations regarding the illegal use of placards is also necessary, emphasizing the serious repercussions of misuse. Overall, the application process aims to ensure that only qualified individuals receive access to disabled parking privileges while maintaining the integrity of the system.

Massachusetts Disabled Parking App 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 #

p.1

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: _______________________

p.2

MAB100_0821
Get Massachusetts Disabled Parking App PDF Form

Form Characteristics

Fact Name Details
Governing Law This application is governed by Massachusetts General Laws, Chapter 90, Section 24B, which outlines the regulations surrounding disabled parking privileges.
Submission Timeline The application must be submitted to Medical Affairs within thirty (30) days of the healthcare provider’s certification to ensure timely processing.
Completeness Requirement All sections of the application must be fully completed. Incomplete applications will be returned without processing, which can delay obtaining your placard or plate.
Healthcare Provider Signature Both the disabled individual and the healthcare provider must sign and date the application, affirming the accuracy of the information provided.
No On-Site Processing Disability parking applications cannot be processed at RMV Service Centers. Submitting the application at a service center may result in longer processing times.

Guidelines on Utilizing Massachusetts Disabled Parking App

To properly complete the Massachusetts Disabled Parking Application form, it is important to gather all necessary personal and medical information beforehand. This ensures that all sections are filled out accurately and completely, which helps in expediting the processing of your application.

  1. Title your application as "Application for Disabled Parking Placard/Plate".
  2. Complete the disabled applicant information in sections A, B, and C:
    • Enter the last name, first name, middle name, and suffix.
    • Provide the date of birth in the format MM/DD/YYYY.
    • If applicable, input the current Massachusetts Learner’s Permit, Driver’s License # or MA ID.
    • Select the gender (M, F, X).
    • Fill in the residential address including street, city, state, and zip code.
    • Indicate whether the mailing address is the same as the residential address.
    • Provide your email and phone type/number.
    • If desired, complete the emergency contact information.
  3. Select the type of service you are applying for in section B by checking one of the options provided for either a placard or plate.
  4. Read through the certification rules in section C. Ensure you understand the legal implications regarding misuse of the disabled parking privileges.
  5. Sign and date the application in the designated areas, confirming accuracy under penalties of perjury.
  6. Have your healthcare provider complete sections D and E:
    • Provide their name, address, and medical qualifications.
    • They should select the appropriate box regarding your ability to operate a vehicle.
    • Your healthcare provider must then complete the clinical diagnosis and check any applicable items related to your condition.
    • Finally, they will need to sign and date the form certifying the accuracy of the information provided.
  7. Submit the completed application by mailing it to Medical Affairs at the address provided or via any other permitted method, making sure to do it within thirty (30) days of your healthcare provider’s certification.

After completing these steps, keep a copy of the application for your records. Ensure your application is fully signed and submitted in a timely manner. This will help you avoid any unnecessary delays in receiving your disabled parking placard or plate.

What You Should Know About This Form

What is the purpose of the Massachusetts Disabled Parking App form?

The Massachusetts Disabled Parking App form is designed for individuals with disabilities to request a parking placard or plate that allows them to park in designated disabled parking spaces. The disabled person must complete specific sections of the application, and a healthcare provider must also provide their certification. This ensures that the need for a disability designation is appropriately documented and verified.

What information is required to complete the application?

To fill out the application, the disabled person must provide their full name, date of birth, residential and mailing addresses, Social Security number, and contact information. It is crucial to fill out all fields in sections A, B, and C. The healthcare provider is responsible for completing sections D and E, which includes their professional opinion on the applicant's ability to operate a vehicle safely and their clinical diagnosis.

How do I submit the completed application?

After completing the application, it must be mailed to the address specified on the form: Medical Affairs, PO Box 55889, Boston, MA 02205-5889. It is important to submit the application within thirty days of the healthcare provider's certification date. Note that you should not drop off the application at an RMV Service Center, as they do not process these applications, which might lead to additional processing time.

Can I apply for a disabled parking placard if I do not own a vehicle?

Yes, you can apply for a disabled parking placard even if you do not own a vehicle. The placard allows individuals with disabilities to have accessible parking, which is crucial for their mobility. There is no fee for obtaining a placard, and it is not a requirement to have a vehicle registered in your name to receive one.

What are the consequences of providing false information on the application?

Providing false information on the application can have serious repercussions. It is illegal to submit incorrect details or forge signatures. If found guilty, individuals may face substantial fines, potential imprisonment, or both. Additionally, misuse of a disabled parking placard can result in heavy fines and the suspension of parking privileges. Therefore, honesty and transparency in the application process are essential.

Common mistakes

Applying for a disabled parking placard or plate in Massachusetts can be straightforward, but many individuals make common mistakes that can lead to delays or rejections. Understanding these pitfalls can help ensure the application is processed smoothly and efficiently. Here are seven frequent mistakes to watch out for:

One of the most significant errors is submitting an incomplete application. Each section of the application must be carefully filled out, including the personal information of the disabled applicant. Omitting even a single detail, such as a date of birth or a social security number, can result in the application being returned without processing. Thoroughly check each section before mailing the application.

Another common mistake is failing to obtain the required signatures. Both the disabled individual and their healthcare provider must sign and date the application. If either signature is missing, the RMV will simply return the application. It is crucial to ensure that all necessary signatures are secured before submission.

Applicants often forget the 30-day submission window following the healthcare provider’s certification. The completed application must reach the Medical Affairs office within this timeframe. Delays can lead to complications, so setting a reminder to mail the application promptly is a wise move.

Some individuals mistakenly drop off their applications at a RMV Service Center. This can be an added source of delay since these centers do not process disability parking applications. Instead, mailing the application directly to Medical Affairs can help streamline the process, saving valuable time.

Providing inaccurate or false information is a serious issue that could result in prosecution. This includes slipping up on the details regarding residency, medical conditions, and the applicant’s need for disability access. Be honest and precise when filling out the application to avoid severe penalties and ensure compliance with the law.

Applicants should also pay attention to the type of service they are requesting. There are specific categories for placards and plates, each with its own requirements. Failing to select the correct type—whether it’s a placard, a standard plate, or a motorcycle plate—can lead to inappropriate processing and denial of the application.

Finally, one of the less visible mistakes involves not providing adequate medical documentation. Although the healthcare provider certifies that the applicant qualifies for disabled parking, additional documentation may be required. For example, detailed medical assessments or specific test results may need to be included depending on the applicant's health conditions. Always check for any supplementary documents that might be necessary before submission.

By avoiding these common mistakes, applicants can enhance the likelihood of a smooth and successful application process for their Massachusetts disabled parking placard or plate.

Documents used along the form

The Massachusetts Disabled Parking App form is a crucial document for individuals seeking to obtain a parking placard or plate designed for persons with disabilities. Along with this form, several other documents and forms often come into play during the application process. Below is a list of these additional documents, each serving a distinct purpose in the overall submission and approval operation.

  • Medical Record Release Authorization: This document allows a healthcare provider to share relevant medical information with the Registry of Motor Vehicles (RMV) to validate the applicant's disability claim.
  • Physician's Statement: A separate form or letter from a healthcare provider detailing the applicant’s medical condition, mobility limitations, and need for a disabled parking permit may be required.
  • Proof of Identity: A copy of a government-issued identification, such as a driver’s license or state ID, may be necessary to confirm the identity of the applicant.
  • Proof of Residency: Documentation establishing the applicant's residence in Massachusetts, such as a utility bill or lease agreement, is often requested to verify the address provided on the application.
  • Veteran's Administration Letter (for DV Plates): Veterans applying for Disabled Veteran plates must provide a letter from the VA confirming their disability rating, ensuring all conditions are met for eligibility.
  • Temporary Disability Certificate: If the applicant has a temporary disability, a certification from a healthcare provider may be needed, outlining the duration and nature of the condition.
  • Emergency Contact Information Form: While optional, this is sometimes requested to provide an emergency contact in case any issues arise while the applicant is parked.
  • Processing Fee Payment Receipt: Applicants seeking special license plates may need to provide proof of payment for registration fees related to the issuance of the plates.
  • Application for Variance: If an applicant cannot meet certain standard requirements, a formal request for a variance may be submitted to explain their particular circumstances.

Gathering these documents can streamline the application process and reduce potential delays. It’s essential for applicants to ensure that they provide all necessary information and documentation to expedite approval of their disabled parking privileges in Massachusetts.

Similar forms

  • Application for a Disabled Person's License Plate: Like the Disabled Parking App form, this application gathers personal information from the applicant, such as their name, address, and healthcare provider details. Both require signatures from the disabled person and a certified healthcare provider, emphasizing the need for medical verification of a disability.
  • Request for Medical Records: Similar to the authorization section in the Disabled Parking App, a request for medical records requires patients to provide their consent for healthcare providers to release sensitive health information. Both documents prioritize the patient's health information and confidentiality.
  • Medicare/Medicaid Application: This application shares a focus on verifying the applicant's eligibility based on specific medical conditions. Each document requires clear personal information and may necessitate a healthcare provider's statement about the medical conditions affecting the applicant's daily life.
  • Social Security Disability Insurance (SSDI) Application: This application, like the Disabled Parking App, includes an assessment of the applicant's disability, requiring detailed personal information and documentation from a healthcare provider. Both forms evaluate the applicant's ability to perform essential daily activities.
  • Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: The HIPAA authorization shares the purpose of allowing healthcare providers to exchange personal health information. Both forms ensure that the individual's rights to their medical records are respected while allowing essential information to be shared for administrative purposes.

Dos and Don'ts

When filling out the Massachusetts Disabled Parking Application form, it is crucial to ensure accuracy and follow the guidelines provided. Here’s a helpful list of what you should and shouldn’t do.

  • Do complete all required sections in full. All fields must be filled out completely to avoid delays.
  • Do ensure both the disabled person and the healthcare provider sign and date the application.
  • Do submit the application within thirty days following the healthcare provider’s certification.
  • Do include any necessary additional documentation that may be required.
  • Don't provide incomplete information. Incomplete applications will be returned.
  • Don't submit the application at RMV Service Centers, as they do not process these requests.
  • Don't allow anyone else to use your placard if you are not in the vehicle.
  • Don't forge signatures or provide false information. This can lead to serious legal consequences.

Misconceptions

Misconceptions about the Massachusetts Disabled Parking App form can lead to confusion and potential issues in the application process. Here are some common misunderstandings, along with clarifications:

  1. Only residents of Massachusetts can apply. While applicants must provide a Massachusetts address, it is possible for out-of-state individuals to apply if they meet specific criteria related to their disabilities.
  2. A healthcare provider's signature is optional. This form cannot be completed without the healthcare provider's signature. Both the disabled person and the healthcare provider must sign for the application to be valid.
  3. All applicants need a driver's license. Applicants do not need to possess a driver's license to receive a disabled parking placard. The application focuses on the individual’s disability rather than their driving status.
  4. Submitting the application at a service center will expedite the process. The RMV Service Centers do not process these applications. Dropping off the form at a service center can actually delay processing times.
  5. Disabled parking placards are only for those who own a vehicle. This is not true. Individuals may apply for a placard without owning a vehicle, as the placard is not tied to vehicle registration.
  6. The application is processed immediately upon submission. Applications typically take time to process, and incomplete forms will lead to delays, so attention to detail is crucial.
  7. There are no consequences for providing false information. Providing false information carries serious legal consequences, including fines and potential jail time. The application emphasizes honesty throughout the process.
  8. Emergency contact information is mandatory. While providing emergency contact information can be beneficial, it is actually optional on the application form.

Understanding these misconceptions helps ensure individuals navigate the Massachusetts Disabled Parking App process successfully, avoiding unnecessary setbacks.

Key takeaways

Filling out and using the Massachusetts Disabled Parking App form can be straightforward if you keep these key takeaways in mind:

  • Complete the Application Thoroughly: All sections must be fully completed. Incomplete applications will be returned, delaying processing.
  • Signatures Required: Both the disabled individual and their healthcare provider must sign and date the form. Ensure both signatures are included to avoid processing issues.
  • Submit Promptly: Applications must reach Medical Affairs within thirty (30) days of the healthcare provider’s certification. Timely submission is crucial for approval.
  • Service Centers Do Not Process Applications: Do not drop off the application at a RMV Service Center. This may lead to additional delays in processing your request.

Browse Other Templates

Ncr Report - This form outlines both the immediate corrections required and the preventive actions to avoid future occurrences.

Da200 Army - The form allows for a return receipt request, ensuring the sender receives confirmation of delivery.

Miles College Transcript Request - Graduates may request one free copy of their transcript within one year of graduation, streamlining their transition into the workforce.