Fill Your Massachusetts Disabled Parking App Form Open This Document Online

Fill Your Massachusetts Disabled Parking App Form

The Massachusetts Disabled Parking Application form is a crucial document for residents seeking disabled parking placards or plates in Massachusetts. It outlines the process and the necessary information that both the applicant and their healthcare provider must provide, emphasizing the importance of accuracy and completeness to avoid processing delays. To ensure your rights to disabled parking are recognized, click the button below to fill out the Massachusetts Disabled Parking Application form.

Securing a Disabled Parking Placard or Plate in Massachusetts is a procedure that necessitates meticulous attention to detail, guided by the Application for Disabled Parking Placard/Plate. Issued by the state's Medical Affairs branch, the comprehensive document demands accurate completion by both the applicant and a certified healthcare provider. For those navigating the nuances of this process, it's crucial to understand the form's stipulations: applications must be sent to Medical Affairs, and cannot be processed at RMV Service Center locations, underlining the importance of mailing them to the specified address in Boston. The form not only requires personal and disability-specific information from the applicant but also a professional medical certification regarding the individual’s ability to safely operate a vehicle, if applicable. Various types of parking accommodations are offered, including placards and plates, each with its unique set of criteria and intended for different kinds of vehicular ownership. Moreover, the document outlines legal mandates against misuse, emphasizing penalties for providing false information or unauthorized use of disabled parking privileges. Importantly, healthcare providers are tasked with a critical role, presented with sections devoted to their insights on the applicant's medical condition, further underscoring the form's dual purpose of adjudicating eligibility while preventing fraudulent claims. This application, thus, serves as a vital tool in ensuring that Massachusetts’s disabled parking resources are allocated fairly and responsibly, reflecting a concerted effort to accommodate individuals with disabilities while upholding the integrity of the system.

Massachusetts Disabled Parking App Sample

Application for Disabled Parking Placard/Plate

Mail to: Medical Affairs, PO Box 55889, Boston, MA 02205-5889857-368-8020mass.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 #

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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

 

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: _______________________

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MAB100_0821

Document Information

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Fact Details
Application Submission This application for a Disabled Parking Placard/Plate must be mailed to the specified address: Medical Affairs, PO Box 55889, Boston, MA 02205-5889.
Contact Information For inquiries, applicants can contact 857-368-8020 or visit mass.gov/rmv for more information.
Applicant's Responsibility The application must be completed in the disabled person's name, including sections A, B, and C, with required signatures and dates.
Healthcare Provider's Role Healthcare providers are required to complete sections D and E of the application to verify the disability.
Submission Deadline The completed application must be submitted to Medical Affairs within thirty (30) days of the healthcare provider's certification.
Service Centers RMV Service Center locations do not process disability parking applications. Applications must be mailed directly.
Placard/Plate Options Applicants can choose between a placard, plate, motorcycle plate, or DV plate based on eligibility and vehicle registration status.
Legal Implications Providing false information, misuse of the placard/plate, possessing/displaying a counterfeit placard, and forging a healthcare provider's signature are illegal actions under Massachusetts Law.

Guidelines on Filling in Massachusetts Disabled Parking App

Filing an Application for a Disabled Parking Placard or Plate in Massachusetts requires careful attention to detail to ensure the request is processed smoothly and without unnecessary delays. As the process is handled exclusively through mail to the Medical Affairs department and given its specific stipulations, including time-bound submission and rigorous documentation requirements, it is critical to follow each step meticulously. This guide aims to navigate you through the necessary steps to fill out the application successfully.

  1. Start by gathering all required information to prevent any interruptions once you begin filling out the form.
  2. Write the disabled person's last name, first name, middle name, and suffix in the designated spaces in section A.
  3. Enter the disabled person's date of birth in the format MM/DD/YYYY.
  4. If applicable, provide the Current Massachusetts Learner’s Permit, Driver’s License number, or MA ID, and select the appropriate gender designation (M, F, or X).
  5. Under Residential Address, fill in the complete street address, including apartment number if applicable, city, state, and ZIP code where the disabled person resides.
  6. For the Mailing Address, mark the checkbox if it is the same as the residential address. If not, provide the mailing address details similarly.
  7. Provide an email address and mark the preferred type of phone (Cell, Home, or Work) before entering the phone number in the designated space.
  8. (Optional) Fill in the emergency contact information by providing name, email, marking the type of phone, and entering the phone number.
  9. In section B, select the type of service needed: Placard, Plate, Motorcycle Plate, or DV Plate. Each option has specific criteria and requirements.
  10. Read through the certification and signature of applicant rules in section C carefully. Check that you understand the legal obligations and consequences for misuse of the disabled parking benefits.
  11. Sign your name in section C to affirm the application's truthfulness and completeness, then date the application.
  12. For sections D and E, these need to be filled out by your healthcare provider. Ensure that they complete every part, including the clinical diagnosis without using ICD codes, the determination on mobility, and their professional opinion on your ability to safely operate a vehicle if applicable.
  13. If applying for a DV Plate, make sure your healthcare provider includes a letter from the Veteran’s Administration listing service-connected disabilities.
  14. Confirm that your healthcare provider signs and dates the form in section E.
  15. Before mailing the application to Medical Affairs, double-check that all fields are filled accurately and completely. Incomplete applications will be returned and will not be processed.
  16. Mail the completed application within thirty (30) days of the healthcare provider’s certification to the specified address: Medical Affairs, PO Box 55889, Boston, MA 02205-5889.

Upon completion and mailing of your application, it will be reviewed by the Medical Affairs department. Remember, applications cannot be processed at RMV Service Center locations. Ensure all documentation is correct and submitted on time to avoid any processing delays. The careful completion of each step is key to securing your disabled parking placard or plate, thereby providing you with the necessary parking accessibility.

More About Massachusetts Disabled Parking App

Who can apply for a Disabled Parking Placard or Plate in Massachusetts?

Any Massachusetts resident with a documented disability, as certified by a healthcare provider, may apply for a Disabled Parking Placard or Plate. The disability must restrict mobility or impair the safe operation of a vehicle as stated by a healthcare provider.

What is the difference between a Placard and a Plate, and how do I choose which one to apply for?

A placard is a portable sign that can be moved from one vehicle to another and is used by individuals with disabilities when they travel in any vehicle. A plate is a permanent license plate designated for a vehicle registered in the name of the disabled individual. Applicants should choose based on whether they need the flexibility to use multiple vehicles (Placard) or if their transportation needs are met through a single, personally registered vehicle (Plate).

Is there a fee to apply for a Disabled Parking Placard or Plate?

There is no fee required to apply for or obtain a Disabled Parking Placard. However, standard vehicle registration fees apply for Disabled Parking Plates and DV (Disabled Veteran) Plates.

What information is required for the application?

The application must include comprehensive disabled applicant information, a certification of disability by a healthcare provider, and, for DV Plate applicants, a letter from the Veteran’s Administration. All sections (A, B, C, D, and E) of the application form must be completed, including the applicant's personal information, vehicle information (if applicable), and the medical certification of disability.

What is the deadline for submitting the application?

The application must be submitted to the Medical Affairs department within thirty (30) days of the healthcare provider’s certification to ensure the condition is current and accurately assessed.

Where should I mail my completed application?

The completed application should be mailed to Medical Affairs, PO Box 55889, Boston, MA 02205-5889. It is important to note that RMV Service Centers do not process disability parking applications; mailing it directly is necessary.

Can I drop off my application at an RMV Service Center for processing?

No, RMV Service Center locations do not process disability parking applications. Applications mailed directly to Medical Affairs are processed promptly, and dropping off at a service center location may delay the process.

What happens if I misuse the Disabled Parking Placard or Plate?

Misuse of disabled parking privileges, including allowing others to use your placard or plate when you are not present or providing false information during the application, is illegal and subjects you to penalties. These may include motor vehicle citation fines up to $500 for the first offense, potential license suspension, and revocation of disabled parking privileges.

Common mistakes

Filling out the Massachusetts Disabled Parking Application form requires attention to detail. Common mistakes can lead to delays or the rejection of the application. Here are eight errors applicants should avoid:

  1. Leaving sections incomplete, particularly the disabled person’s information in sections A, B, and C. Every field must be filled out to ensure the application is processed.
  2. Not getting the healthcare provider's signature and date on the application. This is mandatory for the review and approval process.
  3. Submitting the application after the 30-day period following the healthcare provider's certification has expired. Timeliness matters for the validity of the medical certification.
  4. Dropping off the application at an RMV Service Center instead of mailing it directly to Medical Affairs. Service centers do not process these applications, which can add to the processing time.
  5. Failing to provide additional documentation when it's required. Sometimes, more information is necessary to approve the application.
  6. Applying for the wrong service type (e.g., plate instead of placard) without understanding the specific requirements and fees associated with each.
  7. Inaccurately reporting medical status or conditions in the certification section or attempting to alter the healthcare provider’s signature. Honesty is critical, and violations can lead to severe penalties.
  8. Forgetting to authorize the release of medical records by the healthcare provider, and for DV plate applicants, not authorizing the Veteran’s Administration to release information about service-connected disability ratings.

By avoiding these common mistakes, applicants can help ensure their application for a Disabled Parking Placard or Plate in Massachusetts is processed efficiently and without unnecessary delays.

Documents used along the form

When applying for a Disabled Parking Placard or Plate in Massachusetts, applicants and healthcare providers need to navigate through a comprehensive process that ensures only eligible individuals receive these accommodations. To streamline the application, it is not uncommon for additional forms and documents to be required, serving to validate the information provided on the application and to adhere to regulatory requirements. These documents not only reinforce the legitimacy of the application but also provide a holistic view of the applicant's needs and qualifications.

  1. Proof of Identification - A government-issued ID, such as a driver's license or Massachusetts ID card, confirms the applicant's identity.
  2. Proof of Residency - Documents like utility bills or rental agreements establish the applicant's residence in Massachusetts.
  3. Veteran’s Administration (VA) Disability Letter - For applicants applying for a DV Plate, this letter from the VA outlines service-connected disabilities and ratings.
  4. Certificate of Blindness - In cases where legal blindness is the basis for the application, this document issued by a recognized authority verifies the condition.
  5. Recent Medical Records - Records that detail the applicant's disability and its impact on mobility provide crucial verification for the healthcare provider’s assessment.
  6. FEV1 Test Results - For individuals with chronic lung disease, spirometry test results must be included to demonstrate the extent of respiratory impairment.
  7. Pulmonary Function Test Results - Required for applicants with pulmonary conditions, these results support claims of respiratory limitations.
  8. Documentation on the Use of Portable Oxygen - If the applicant requires portable oxygen, medical documentation must outline the necessity of such equipment for mobility.
  9. Letter of Explanation - For any special circumstances or additional information not covered in the initial application, a detailed letter from the applicant can provide further insights into their condition and needs.

The ensemble of these documents, complementing the Massachusetts Disabled Parking Application, ensures a thorough and fair assessment of each request for parking accommodations. By providing a detailed and documented justification of their condition, applicants can help the relevant authorities understand their mobility challenges and make informed decisions regarding eligibility. This careful process underscores the importance of maintaining the integrity of accommodations for individuals with disabilities, ensuring that resources are allocated to those with legitimate needs.

Similar forms

The Massachusetts Disabled Parking Application form shares similarities with other essential documents designed to assist individuals with disabilities, each having its distinct set of requirements and sections aimed at evaluating eligibility and necessary accommodations. These documents, while serving different purposes, often maintain a standard of gathering detailed information to ensure the proper support is made available to those who qualify.

The Social Security Disability Benefits Application: The Massachusetts Disabled Parking Application form mirrors the Social Security Disability Benefits Application in several ways. Firstly, both necessitate detailed personal information alongside health conditions verified by medical professionals to determine eligibility. Just as the parking application requires a healthcare provider's certification regarding the applicant's mobility limitations or medical conditions, the Social Security benefits application demands medical evidence and sometimes a detailed account of how one's disabilities affect daily activities. Moreover, both applications emphasize the legality of the information provided, warning against the consequences of falsification.

The ADA Reasonable Accommodation Request Form: Another document sharing similarities with the Massachusetts Disabled Parking Application form is the ADA Reasonable Accommodation Request Form often used by employees to request adjustments or modifications in the workplace due to a disability. Both forms require the demonstration of a medical condition or disability certified by a healthcare provider, detail the specific accommodations or modifications sought (be it parking space or workplace adaptations), and underscore the applicant's rights and responsibilities. Furthermore, they highlight the confidentiality of the disclosed medical information, except as required for processing and verification purposes.

Dos and Don'ts

When applying for a Massachusetts Disabled Parking Placard or Plate, it's important to follow the guidelines carefully to ensure your application is processed smoothly and efficiently. Below are seven dos and don'ts that can help guide you through the application process:

Dos:

  • Complete all requested information in the sections designated for the disabled person (Sections A, B, and C). Make sure no fields are left blank.
  • Ensure that both the disabled person and healthcare provider sign and date the application where required. These signatures are crucial for its validity.
  • Submit the application to Medical Affairs within thirty (30) days of receiving the healthcare provider’s certification. Timeliness is key.
  • Provide a valid Massachusetts address where you actually reside. This ensures that any communication or the placard/plate itself is sent to the right location.
  • Read and understand the rules and acknowledgments section to avoid misuse of the disabled parking privileges, which could result in significant penalties.

Don'ts:

  • Don't drop off the application at an RMV Service Center, as RMV locations do not process these applications. Mailing it directly to the Medical Affairs is the prescribed method.
  • Don't submit incomplete applications. An application lacking any required information or documentation will not be processed and will be returned to you for completion.

By carefully following these guidelines, you can help ensure your application for a Disabled Parking Placard or Plate in Massachusetts is filled out correctly and processed without unnecessary delays.

Misconceptions

When it comes to applying for a Massachusetts Disabled Parking Placard or Plate, there's plenty of room for confusion. Clearing up these misconceptions is critical for a smooth application process. Here are ten common misunderstandings and the reality behind each:

  • Any healthcare provider can sign off on the form. Only certain healthcare providers, including medical doctors, chiropractors, nurse practitioners, physician assistants, osteopaths, optometrists (for blindness only), and podiatrists, are authorized to complete and sign the healthcare section of the application.
  • Applications can be processed at RMV service centers. The Registry of Motor Vehicles (RMV) doesn’t process disability parking applications at their service centers. All forms must be mailed directly to the Medical Affairs office, as dropping them off at a service center could lead to delays.
  • A disability placard allows parking in any spot for free. While a disabled parking placard affords certain parking privileges, it doesn't grant carte blanche to park anywhere. Restrictions apply, especially regarding private property and designated no-parking zones.
  • The form can be submitted at any time after healthcare provider certification. The form must be submitted to the Medical Affairs office within 30 days of being certified by a healthcare provider, ensuring that all information is current and accurately reflects the applicant's needs.
  • A photo ID is required to apply. While the form requests an ID number for identification, it explicitly does not require a photo to be submitted with the application. The number from a Massachusetts Learner’s Permit, Driver’s License, or MA ID is sufficient.
  • The application is lengthy and complicated. The application form is designed to be straightforward, requesting essential information from the applicant and healthcare provider to verify the need for a disabled parking placard or plate.
  • Incomplete applications will be processed with delays. In truth, any application received incomplete will not be processed at all and will be returned to the applicant, emphasizing the importance of thoroughly reviewing and completing the form before submission.
  • Only permanent placards are available. Massachusetts offers both temporary and permanent placards, catering to individuals with short-term injuries or conditions as well as those with permanent disabilities.
  • There is a fee required for a placard. Contrary to this common misconception, there is no fee required to apply for or receive a disability placard in Massachusetts.
  • Anyone with a disability qualifies for a DV (Disabled Veteran) Plate automatically. DV Plates have specific requirements, including a vehicle registered in the applicant's name, a service-connected disability rating of at least 60%, and a letter from the Veterans Administration.

Understanding these key points demystifies the process, making it more accessible for those who need it most. It’s essential for applicants and their healthcare providers to carefully review the requirements and submit a complete, timely application to avoid unnecessary delays or rejections.

Key takeaways

When applying for a Disabled Parking Placard or Plate in Massachusetts, it's essential to understand and comply with all specified requirements to ensure the application process goes smoothly. Below are seven key takeaways to guide applicants through this process:

  • Complete all sections of the application. The form requires detailed information about the disabled person in sections A, B, and C, while a healthcare provider must fill out sections D and E. Missed details can lead to delays or the return of the application.
  • Applications must be submitted within 30 days of healthcare provider certification, emphasizing the importance of timeliness in submitting the form to Medical Affairs.
  • Disability parking applications are not processed at RMV Service Center locations. To avoid unnecessary delays, send the completed form directly to the provided address or as instructed on the form.
  • A placard is available at no fee and does not require the disabled person to have a vehicle registered in their name. This makes obtaining a placard accessible for individuals who may not own a vehicle but require parking accommodations.
  • Misuse of the disabled parking placard is illegal and carries severe penalties, including high fines and the possibility of license suspension. It's crucial to understand and follow all rules related to the placard's use to maintain parking privileges.
  • Healthcare provider validation is a critical component of the application. The provider must certify the applicant's disability and their need for a disabled parking placard or plate, without which the application cannot proceed.
  • The application warns against providing false information, forging healthcare provider signatures, and possessing or displaying counterfeit placards. These actions are prosecutable offenses under Massachusetts law, highlighting the importance of honesty and accuracy in the application process.

This application process is designed to ensure that disabled parking accommodations are provided to those genuinely in need, based on a healthcare provider's assessment and certification. By carefully following these guidelines, applicants can facilitate a smooth process in acquiring a disability parking placard or plate.

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