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In Massachusetts, obtaining a disabled parking placard or plate involves a specific application process designed to ensure that individuals with disabilities receive the accommodations they need. The application form requires completion in the name of the disabled person, and both the applicant and their healthcare provider must provide signatures and dates. Essential information includes personal details such as the applicant’s name, date of birth, and Social Security number, as well as the type of service requested—whether a placard, plate, or motorcycle plate. Notably, a placard is issued at no cost and does not require the applicant to own a vehicle, while registration fees apply for plates. The healthcare provider plays a critical role in the process, as they must certify the applicant's medical condition and its impact on their ability to operate a vehicle safely. The form emphasizes the importance of accuracy; incomplete applications will be returned, and providing false information can lead to serious legal consequences. Additionally, applicants must submit their completed forms to the Medical Affairs office within thirty days of the healthcare provider's certification to avoid delays. Understanding these requirements is crucial for a smooth application process and to ensure compliance with state regulations.

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 #

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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
Click for Massachusetts Disabled Parking App File

File Breakdown

Fact Name Details
Application Submission The completed application must be mailed to Medical Affairs at PO Box 55889, Boston, MA 02205-5889.
Signatures Required Both the disabled person and the healthcare provider must sign and date the application for it to be valid.
Processing Time The application must be submitted within 30 days of the healthcare provider’s certification to avoid delays.
Legal Compliance Misuse of the disabled parking placard can result in fines, license suspension, and revocation of parking privileges under M.G.L. Chapter 90, Section 24B.

Guide to Using Massachusetts Disabled Parking App

Follow these steps to complete the Massachusetts Disabled Parking Application form. Ensure all necessary information is filled out accurately to avoid delays in processing.

  1. Begin with Section A. Provide the disabled person's Last Name, First Name, Middle Name, and Suffix. Fill in the Date of Birth in MM/DD/YYYY format.
  2. Enter the Current Massachusetts Learner’s Permit, Driver’s License # (if applicable) or MA ID, and select the Gender from the options: Male, Female, or Non-binary.
  3. Complete the Residential Address fields, including street number, apartment number (if applicable), city, state, and zip code.
  4. If the mailing address is different, fill in the Mailing Address fields. If it is the same, check the box indicating this.
  5. Provide an Email address and a Phone Number. Specify the type of phone (Cell, Home, or Work).
  6. Optionally, fill in the Emergency Contact Information section with the name, phone number, and type of phone.
  7. Move to Section B. Select the type of service you are applying for: Placard, Plate, Motorcycle Plate, or DV Plate.
  8. In Section C, read the rules carefully. Acknowledge that you understand them by checking the acknowledgment box.
  9. Sign and date the application in the space provided for the disabled person.
  10. Proceed to Section D. The healthcare provider must complete this section. They will assess the applicant's medical qualifications.
  11. Ensure the healthcare provider fills in their Last Name, First Name, and Address. Include their NPI # and Board of Registration in Medicine #.
  12. The healthcare provider must sign and date the application in Section E, certifying that the information is accurate.
  13. Once completed, mail the application to Medical Affairs, PO Box 55889, Boston, MA 02205-5889.

Get Answers on Massachusetts Disabled Parking App

  1. What is the process for applying for a disabled parking placard or plate in Massachusetts?

    To apply for a disabled parking placard or plate, complete the application form in the name of the disabled person. Ensure all sections (A, B, and C) are filled out, and have the healthcare provider complete sections D and E. Submit the signed application to Medical Affairs within 30 days of the healthcare provider’s certification. Mail it to Medical Affairs, PO Box 55889, Boston, MA 02205-5889. Remember, incomplete applications will be returned.

  2. What information is required on the application form?

    The application requires detailed information, including:

    • Full name and date of birth of the disabled person
    • Social Security number
    • Residential and mailing addresses
    • Type of service requested (placard or plate)
    • Healthcare provider's certification regarding the applicant's medical condition

    All fields must be completed accurately to avoid delays.

  3. What are the consequences of misusing a disabled parking placard?

    Misusing a disabled parking placard can lead to significant penalties. Individuals may face fines up to $500 for the first offense. Additionally, misuse can result in license suspension and revocation of disabled parking privileges. It is crucial to adhere to the rules outlined in the application to avoid these consequences.

  4. Can I submit my application at an RMV Service Center?

    No, RMV Service Center locations do not process disability parking applications. Submitting the application at a service center can add processing time. It is recommended to mail the application directly to Medical Affairs for timely processing.

  5. What if I need additional documentation?

    In some cases, additional documentation may be required to complete the application process. This could include medical records or further verification of the applicant's condition. Be prepared to provide any necessary information promptly to avoid delays in processing your application.

Common mistakes

Filling out the Massachusetts Disabled Parking Application can be a straightforward process, but many applicants make common mistakes that can lead to delays or even rejection. One significant error is submitting an incomplete application. All fields in sections A, B, and C must be filled out completely in the disabled person's name. Missing information can result in the application being returned, prolonging the time it takes to receive a placard or plate.

Another frequent mistake involves the signatures. Both the disabled person and the healthcare provider must sign and date the application. Failing to obtain the necessary signatures can halt the processing of the application. It is essential to double-check that all required signatures are present before submission.

Some applicants also overlook the submission timeline. The application must be sent to Medical Affairs within thirty days of the healthcare provider's certification. If the application is submitted late, it may not be processed, requiring the applicant to start over. Keeping track of dates is crucial to ensure timely submission.

Lastly, many individuals do not provide adequate documentation. Additional documentation may be required based on the type of service requested. For instance, applicants for Disabled Veteran plates must include a letter from the Veteran’s Administration. Failing to include necessary documents can lead to delays or denials. Always review the requirements carefully to ensure a smooth application process.

Documents used along the form

When applying for a disabled parking placard or plate in Massachusetts, several other forms and documents may be necessary to support your application. These documents help ensure that your application is complete and meets all requirements. Here’s a list of commonly used forms and documents that may accompany the Massachusetts Disabled Parking Application:

  • Medical Certification Form: This form is filled out by a healthcare provider to confirm the applicant's medical condition that qualifies them for a disabled parking permit. It provides essential details about the applicant's health status.
  • Proof of Residency: A document that verifies the applicant's current address. This could be a utility bill, lease agreement, or any official correspondence that includes the applicant’s name and address.
  • Social Security Card: A copy of the applicant's Social Security card may be required to verify their identity and Social Security number as part of the application process.
  • Driver's License or ID Copy: A photocopy of the applicant's Massachusetts driver’s license or state-issued ID helps confirm their identity and eligibility for the placard or plate.
  • Veteran’s Administration Documentation: For those applying for disabled veteran plates, documentation from the VA is needed to establish service-connected disabilities and their severity.
  • Emergency Contact Form: Although optional, this form provides information about a person to contact in case of an emergency, ensuring that someone is informed about the applicant's situation if necessary.
  • Application for Disability Benefits: If the applicant is receiving disability benefits, this application may be required to provide evidence of their disability status.
  • Temporary Disability Letter: If applicable, a letter from a healthcare provider indicating the temporary nature of the disability can support the need for a temporary placard.
  • Ambulatory Aids Documentation: If the applicant uses aids like wheelchairs or walkers, documentation may be necessary to explain their use and need for accessible parking.
  • Certification of Blindness: For legally blind applicants, a certificate that verifies blindness may be submitted instead of a standard medical certification.

Gathering these documents can streamline the application process and help avoid delays. Make sure to review each requirement carefully to ensure that your application is complete and accurate. This will enhance your chances of receiving your disabled parking privileges without unnecessary complications.

Similar forms

The Massachusetts Disabled Parking Application form serves a critical purpose in ensuring that individuals with disabilities have access to necessary parking accommodations. Several other documents share similarities with this application, particularly in their structure, purpose, and requirements. Below is a list of ten documents that are comparable to the Massachusetts Disabled Parking Application form:

  • Driver's License Application: Like the disabled parking application, this form requires personal information, identification, and often a signature. Both documents must be completed accurately to avoid delays in processing.
  • Voter Registration Form: This form also collects personal details and requires a signature. It ensures that individuals are eligible to vote, similar to how the disabled parking application verifies eligibility for parking privileges.
  • Medical Leave Request Form: Both documents necessitate a healthcare provider's verification. They require signatures and may involve a review process to confirm eligibility based on medical conditions.
  • Social Security Disability Application: This application gathers extensive personal and medical information to determine eligibility for benefits. Like the disabled parking form, it requires thorough documentation and often a healthcare provider's input.
  • State Identification Card Application: Similar in structure, this form requests personal details and proof of residency. It also requires a signature and verification of identity, akin to the disabled parking application.
  • Health Insurance Enrollment Form: This document collects personal and health-related information to establish coverage. Both forms require accurate information and may involve a healthcare provider's certification.
  • Homeowner's Insurance Application: While focused on property, this application also requires personal details and signatures. It involves a review process to confirm eligibility, similar to the disabled parking application.
  • Permit Application for Building or Renovation: This document requires detailed information about the applicant and the project, along with signatures. Both applications undergo scrutiny to ensure compliance with regulations.
  • College Admission Application: This form collects personal information, academic history, and often requires recommendations or endorsements. Both documents necessitate careful completion and may impact future opportunities.
  • Employment Application: Like the disabled parking application, this form collects personal and professional information. It often requires signatures and is subject to verification processes to ensure accuracy.

Each of these documents shares a common goal: to verify eligibility and ensure that the information provided is accurate and complete. Completing them correctly is essential to avoid delays or complications in processing.

Dos and Don'ts

When filling out the Massachusetts Disabled Parking Application form, it is essential to follow specific guidelines to ensure a smooth process. Here is a list of things you should and shouldn't do:

  • Do complete all sections of the application, including the disabled person’s information and healthcare provider’s details.
  • Do ensure both the disabled person and healthcare provider sign and date the application.
  • Do submit the application to Medical Affairs within thirty (30) days of the healthcare provider’s certification.
  • Do provide accurate information to avoid delays or rejection of your application.
  • Do keep a copy of the completed application for your records.
  • Don't submit an incomplete application; it will be returned for corrections.
  • Don't allow someone else to use your placard if you are not in the vehicle.
  • Don't provide false information, as this can lead to legal consequences.
  • Don't drop off the application at an RMV Service Center, as they do not process disability parking applications.

Misconceptions

  • Misconception 1: The application can be submitted at any RMV Service Center.

    • This is incorrect. RMV Service Centers do not process disability parking applications. Submitting your application at a service center may lead to delays in processing.

  • Misconception 2: Only the disabled person needs to sign the application.

    • Both the disabled person and the healthcare provider must sign and date the application. Missing signatures will result in the application being returned.

  • Misconception 3: Incomplete applications will still be processed.

    • This is false. An incomplete application will not be processed and will be returned. Ensure all required fields are filled out correctly.

  • Misconception 4: There is no time limit for submitting the application after the healthcare provider's certification.

    • Actually, the application must be submitted within thirty (30) days of the healthcare provider’s certification. Delays could jeopardize your eligibility.

Key takeaways

  • Complete the application accurately. Ensure that all fields in the disabled person’s section are filled out completely. Missing information can lead to delays.

  • Signatures are essential. Both the disabled individual and their healthcare provider must sign and date the application. This is a critical step that should not be overlooked.

  • Submit promptly. The application must be sent to Medical Affairs within thirty days of the healthcare provider’s certification. Delays can complicate your request.

  • Avoid service centers. Do not drop off the application at RMV Service Centers, as they do not process these applications. This could increase your processing time.

  • Understand the service types. Choose the correct type of placard or plate based on your situation. Some options require vehicle registration, while others do not.

  • Be aware of the rules. Familiarize yourself with the legalities surrounding disabled parking. Misuse can lead to hefty fines and loss of privileges.

  • Provide complete medical information. The healthcare provider must include relevant medical details, including the clinical diagnosis and any necessary supporting documents.

  • Review before submission. Double-check the entire application for accuracy. Errors or omissions can lead to processing delays or denials.