Form 1776, Physician’s Statement for Disabled License Plates or Placards Instructions
This form contains 31 fields organized into 7 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Certifier Details (Name, Phone, License) | ||
| Printed Name of Physician or Licensee | Text |
Enter the certifying physician’s or licensee’s full printed name (Last, First, Middle) exactly as it appears on their professional records.
|
| Physician's Phone Number | Text |
Enter the best contact phone number for the certifying physician or licensee, including area code.
|
| License Number | Text |
Enter the professional license or credential number issued to the certifying physician or licensee by the licensing authority.
|
| State of License | Text |
Enter the U.S. state that issued the certifying physician’s or licensee’s professional license.
|
| Certifier Type (Select One) | ||
| Adv. Practice Registered Nurse | Checkbox |
Check this box if the person completing and signing this form is an Advanced Practice Registered Nurse certifying the applicant's disability.
|
| Physician Assistant | Checkbox |
Check this box if the person completing and signing this form is a Physician Assistant certifying the applicant's disability.
|
| Chiropractor | Checkbox |
Check this box if the person completing and signing this form is a Chiropractor certifying the applicant's disability.
|
| Physical Therapist | Checkbox |
Check this box if the person completing and signing this form is a Physical Therapist certifying the applicant's disability.
|
| Podiatrist | Checkbox |
Check this box if the person completing and signing this form is a Podiatrist certifying the applicant's disability.
|
| Optometrist | Checkbox |
Check this box if the person completing and signing this form is an Optometrist certifying the applicant's disability.
|
| Licensed Physician | Checkbox |
Check this box if the person completing and signing this form is a Licensed Physician certifying the applicant's disability.
|
| Disability Duration (Permanent/Temporary and Expiration Date) | ||
| Permanent Disability | Checkbox |
Check this box when the patient's disability is permanent and there is no expiration date for the disabled person license plate or placard.
|
| Temporary Disability (Provide Expiration Date) | Checkbox |
Check this box when the patient's disability is temporary and you will provide an expiration date (MM/DD/YYYY); a date is required, must be at least 30 days and cannot exceed 180 days from the date of this statement.
|
| Temporary Disability Expiration Date | Date |
Enter the expiration date for the temporary disability as the date when the disability designation should end. Fill only if 'Temporary Disability (Provide Expiration Date)' is 'Yes'.
Depends on:
Temporary Disability (Provide Expiration Date)
|
| Disability Qualification (Select All That Apply) | ||
| Cannot ambulate or walk 50 feet without stopping to rest | Checkbox |
Check this box if the person cannot ambulate or walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic, or other severe disabling condition.
|
| Cannot ambulate or walk without use of or assistance from an assistive device | Checkbox |
Check this box if 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.
|
| Restricted by respiratory or other disease (FEV1 < 1 L or PaO2 < 60 mmHg) | Checkbox |
Check this box if the person’s forced expiratory volume in one second (measured by spirometry) is less than one liter, or the arterial oxygen tension is less than 60 mmHg on room air at rest, indicating respiratory restriction.
|
| Uses portable oxygen | Checkbox |
Check this box if the person uses portable oxygen.
|
| Cardiac condition with functional limitations Class III or IV (AHA) | Checkbox |
Check this box if the person has a cardiac condition whose functional limitations are classified as Class III or Class IV according to American Heart Association standards.
|
| Blind as defined in Section 8.700, RSMo | Checkbox |
Check this box if the person is blind as defined in Section 8.700, RSMo.
|
| General | ||
| Reset | Button | |
| Button | ||
| Patient Information | ||
| Patient Name (Last, First, Middle) | Text |
Enter the patient's full legal name in the order Last, First, Middle.
|
| Driver License Number or Federal Employer I.D. Number | Text |
Enter the patient's driver license number or federal employer identification number as shown on their identification.
|
| Date of Birth | Date |
Enter the patient's date of birth.
|
| Gender | Text |
Enter the patient's gender as recorded in their medical or legal records (e.g., M, F, or other designation).
|
| Street, Rural Route, or P.O. Box | Text |
Enter the patient's mailing street address, rural route, or P.O. Box.
|
| City | Text |
Enter the city for the patient's mailing address.
|
| State | Text |
Enter the state for the patient's mailing address (abbreviation or full name).
|
| Zip Code | Text |
Enter the postal ZIP code for the patient's mailing address.
|
| Signature Date | ||
| Signature Date | Date |
Enter the date the signing health-care professional or licensee provided their signature for this form.
|