MED 10 (02/17/2011)
Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs
movement from one place to another or the ability to walk as defined in Virginia Code §46.2-1240, and that has reached the maximum level of
improvement and is not expected to change even with additional treatment.
Temporarily limited or impaired beginning in the month of ________________ and ending in the month of _______________ (not to exceed 6 months).
Temporarily limited or impaired beginning in the month of ________________ and ending in the month of _______________ (not to exceed 6 months).
Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs
movement from one place to another or the ability to walk as defined in Virginia Code §46.2-1240, and that has reached the maximum level of
improvement and is not expected to change even with additional treatment.
EMPLOYEE STAMP
CUSTOMER CREDIT CARD NUMBER FEE COLLECTEDCREDIT CARD EXPIRATION DATE (mm/yy)
PLATE/PLACARD NUMBER PLACARD EXPIRATION DATE (mm/dd/yyyy)
DMV USE ONLY
LICENSED PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CERTIFICATION
(This section does not have to be completed to renew permanent placards.)
Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (check below)
Cannot walk 200 feet without stopping to rest.
Is restricted by lung disease to such an extent that forced (respiratory)
expiratory volume for one second, when measured by spirometry, is less
than one liter, or the arterial oxygen tension is less than 60 millimeters
of mercury on room air at rest.
Is legally blind or deaf.
MEDICAL PROFESSIONAL NAME
LICENSE NUMBER (required) LICENSE TYPE
OFFICE TELEPHONE NUMBER
( )
OFFICE FAX NUMBER
( )
STATE ISSUING LICENSE (required) LICENSE EXPIRATION DATE (mm/dd/yyyy) (required)
MEDICAL PROFESSIONAL SIGNATURE
DATE (mm/dd/yyyy)
LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION
Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (Checked below)
MEDICAL PROFESSIONAL NAME
LICENSE NUMBER (required) LICENSE TYPE STATE ISSUING LICENSE (required) LICENSE EXPIRATION DATE (mm/dd/yyyy) (required)
MEDICAL PROFESSIONAL SIGNATURE DATE (mm/dd/yyyy)
Cannot walk without the use of or assistance from any of the following:
another person, brace, cane, crutch, prosthetic device, wheelchair, or
other assistive device.
Is severely limited in ability to walk due to an arthritic, neurological, or
orthopedic condition.
Uses portable oxygen.
Has a cardiac condition to the extent that functional limitations are
classified in severity as Class III or Class IV according to standards set
by the American Heart Association.
Has been diagnosed with a mental or developmental amentia or
delay that impairs judgment including, but not limited to, an autism
spectrum disorder.
Has been diagnosed with Alzheimer's disease or another form of
dementia.
Cannot walk without the use of or assistance from any of the
following: another person, brace, cane, crutch, prosthetic device,
wheelchair, or other assistive device.
Other condition that limits or impairs the ability to walk.
Specific condition description must be specified below.
Is severely limited in ability to walk due to an arthritic, neurological
or orthopedic condition.
Cannot walk 200 feet without stopping to rest.
(This section does not have to be completed to renew permanent placards.)
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I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety
concern while walking as described above.
I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents
I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and
affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety
concern while walking as described above.
I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents
I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and
affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
Other condition that limits or impairs the ability to walk.
Specific condition description must be specified below.
OFFICE TELEPHONE NUMBER
( )
OFFICE FAX NUMBER
( )
