Part 3: Medical Eligibility Standards and Medical Professional Certification
As the medical professional(s) executing this document and verifying the nature of the applicant’s disability, I understand that making a
false representation of a person’s disability for the purposes of obtaining any type of disabled parking placard may result in suspension or
revocation of my license and a fine of up to $1,000. As a licensed physician, I certify the individual named in Part 1 has a condition that
constitutes him/her as a person with disabilities.
Length of Disability: (Check one)
n
Temporary Disability; the duration of this disability is ________________________(maximum 6 months)
n
Permanent Disability
n
Meter-Exempt Disability (Must complete and sign Part 4 also.)
Check all that apply: (MUST
check at least one):
n
Is restricted by a lung disease to such a degree that the person’s forced (respiratory) expiratory volume (FEV) for 1 second, when
measured by spirometry, is less than 1 liter.
n
Uses a portable oxygen device.
n
Has Class III or Class IV cardiac condition according to the standards set by the American Heart Association.
n
Cannot walk without the use of or assistance from a wheelchair, a walker, a crutch, a brace, a prosthetic device, or another person.
n
Is severely limited in the ability to walk due to an arthritic, neurological, oncological, or orthopedic condition.
n
Cannot walk 200 feet without stopping to rest because of one of the above five conditions.
Check all that apply: (MUST
check at least one diagnosis):
n
Amputation of extremity(s) _________________________
n
Arthritis of the ______________________________________
n
Spina Bifida
n
Osteoarthritis of the _________________________________
n
Multiple Sclerosis
n
Chronic Pain due to _________________________________
n
Quadriplegia/Paraplegia
n
Legally Blind with limited mobility
n
Cerebral Palsy
n
Other Diagnosis: _________________________________________________________________________________________
If none of the above conditions apply, list the medical condition that impacts the person’s mobility.
Part 4: Medical Eligibility for Meter-Exempt Parking
The meter-exempt parking certification must be completed only when the applicant qualifies. To qualify, the applicant MUST
have a VALID
Illinois driverʼs license, have an ambulatory disability described in Part 3, and also have one of the following conditions listed below.
Economic need is not a consideration for meter-exempt parking.
The applicant is eligible for meter-exempt parking as provided by statue due to the following PERMANENT medical condition or disability:
Check all that apply:
n
Cannot manage, manipulate or insert coins, or obtain tickets in parking meters/ticket machines due to lack of fine motor control of
BOTH hands.
n
Cannot reach above his/her head to a height of 42 inches from the ground due to a lack of finger, hand or upper-extremity strength
or mobility.
n
Cannot approach a parking meter due to his/her use of a wheelchair or other device for mobility.
n
Cannot walk more than 20 feet due to an orthopedic, neurological, cardiovascular or lung condition in which the degree of debilitation
is so severe that it almost completely impedes the ability to walk.
n
Missing a hand(s) or arm(s) or has permanently lost the use of a hand or arm.
n
Patient is under 18 years of age and incapable of driving.
FOR SECRETARY OF STATE OFFICE USE ONLY
Parking Placard Number: ________________________________ Expiration Date: ______________________________________
Issued By: ___________________________________________ Issue Date: __________________________________________
Medical Professional’s Signature State Professional License Number (NOT NPI#) Today’s Date
Signature of Collaborating/ Supervising Physician
(if signed above by resident/assistant) Supervising State Professional License Number
Medical Professional’s Printed Name Specialty
Office Address City, State, ZIP Code
Medical Professional’s Signature State Professional License Number (NOT NPI#) Today’s Date
Signature of Collaborating/ Supervising Physician
(if signed above by resident/assistant) Supervising State Professional License Number
