Form 1776 - Physician'S Statement For Disabled License Plates/placard
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MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU
FORM
PO BOX 598, JEFFERSON CITY MO 65105-0598
(573) 526-3669
1776
PHYSICIAN’S STATEMENT FOR DISABLED
LICENSE PLATES/PLACARD
(REV. 08-2010)
THIS STATEMENT IS ONLY VALID FOR 90 DAYS.
TO BE COMPLETED BY A AN ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN, CHIROPRACTOR,
PHYSICIAN’S ASSISTANT, PODIATRIST OR OPTOMETRIST. IF YOU HAVE QUESTIONS, CALL (573) 526-3669.
ATTENTION AN ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN,
CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST OR OPTOMETRIST:
Missouri law requires this form to be completed for new applicants and every fourth year for renewal
applicants to obtain disabled person license plates and/or placards. Section 301.142.1, RSMo, defines
“physically disabled” as listed below. Please complete the form in full. At least one disability must
be marked. You must personally sign this form. A stamped signature or signature of a nurse is NOT
acceptable. Disabilities other than those listed below do not qualify the applicant for disabled person
license plates and/or placards.
PATIENT’S NAME
PATIENT’S DLN OR FEIN
DATE OF BIRTH
GENDER
_ _ / _ _ / _ _ _ _
PATIENT’S ADDRESS
CITY
STATE
ZIP CODE
CHECK ONE
PRINTED NAME OF PHYSICIAN/LICENSEE
PHYSICIAN’S TELEPHONE NO.
ADV PRAC REG NURSE
LICENSED PHYSICIAN
(_ _ _) _ _ _ - _ _ _ _
CHIROPRACTOR
LICENSE NUMBER
STATE OF LICENSE
PHYSICIAN’S ASSISTANT
PODIATRIST
OPTOMETRIST
CHECK EACH DISABILITY AS DEFINED IN SECTION 301.142.1, RSMo THAT APPLIES. A PERSON’S AGE
SHALL NOT BE A FACTOR IN DETERMINING A DISABILITY.
The person cannot ambulate or walk 50 feet without stopping to rest due to a severe and
disabling arthritic, neurological, orthopedic condition, or other severe and disabling condition.
The person cannot ambulate or walk without the use of, or assistance from, a brace, cane, crutch,
another person, prosthetic device, wheelchair, or other assistive device.
The person is restricted by a respiratory or other disease to such an extent that the person’s
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 mm/hg on room air at rest.
The person uses portable oxygen.
The person has a cardiac condition to the extent that the person’s functional limitations are
classified in severity as Class III or Class IV according to the standards set by the American
Heart Association.
The person is blind as defined in Section 8.700, RSMo.
30 DAYS
31-60 DAYS
61-90 DAYS
91-120 DAYS
121-150 DAYS 151-180 DAYS
TEMPORARY
PERMANENT
DISABILITY*
DISABILITY
ENTER DATE ®
*A Temporary Placard is valid up to 180 days from the date of this statement. (See reverse for information)
PERSONAL SIGNATURE AND CERTIFICATION OF ADVANCE PRACTICE REGISTERED NURSE,
LICENSED PHYSICIAN, CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST, OR OPTOMETRIST IS
REQUIRED.YOU MUST PERSONALLY SIGN THIS FORM. A STAMPED SIGNATURE OR A SIGNATURE OF
A NURSE IS NOT ACCEPTABLE.
It is a class B misdemeanor for an advance practice registered nurse, licensed physician, chiropractor,
physician’s assistant, podiatrist or optometrist to:
1. Issue, sign, or furnish a statement to any person who does not meet one or more of the conditions
above; or
2. Issue, sign, or furnish a statement to any person for a condition above, the diagnosis of which is
outside his or her scope of license.
A class B misdemeanor is punishable by a fine not to exceed $500 and/or imprisonment not to exceed
6 months.
I certify that I have physically examined the person listed above and determined he or she is
physically disabled for the reason(s) indicated above as required by section 301.142.1, RSMo in
order to obtain disabled license plates and/or placards.
PERSONAL SIGNATURE OF ADVANCE PRACTICE REGISTERED NURSE, LICENSED PHYSICIAN,
DATE
CHIROPRACTOR, PHYSICIAN’S ASSISTANT, PODIATRIST OR OPTOMETRIST.
(A STAMPED SIGNATURE OR SIGNATURE OF A NURSE IS NOT ACCEPTABLE.)
®
_ _ / _ _ / _ _ _ _
MO 860-0412 (08-2010)
SEE REVERSE FOR MORE INFORMATION
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