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Physician Chiropractor Or Advanced Practice Nurse Certification Of BMV 4834 - Ohio
| Physician Chiropractor Or Advanced Practice Nurse Certification Of Form. This is a Ohio form and can be used in Vehicle Registration Bureau Of Motor Vehicles Statewide . |
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OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES HEALTH CARE PROVIDER CERTIFICATION OF ELIGIBILITY FOR DISABILITY LICENSE PLATES NAME OF APPLICANT ADDRESS DATE OF BIRTH CITY SOCIAL SECURITY NUMBER STATE ZIP CODE OHIO REVISED CODE SECTION 4503.44 STATES IN PART THAT: an individual qualifies if that disability limits or impairs the ability to walk as determined by a health care provider. The disability must meet any of the following criteria: 1. Cannot walk two hundred feet without stopping to rest; 2. Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, 3. Is restricted by a lung disease to such an extent that the person's forced (respiratory) expiratory volume for one 4. 5. 6. 7. I, X SIGNATURE OF HEALTH CARE PROVIDER wheelchair or other assistive device; second, when measured by spirometry, is less than one liter or the arterial oxygen tension is less than sixty millimeters of mercury on room air at rest; Uses portable oxygen; 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 standards set by the American Heart Association; Is severely limited in the ability to walk due to an arthritic, neurological or orthopedic condition; A person that is blind. certify that the above named applicant has a disability that limits or impairs the ability to walk as defined above by Ohio Revised Code section 4503.44. NAME OF HEALTH CARE PROVIDER ADDRESS CITY LICENSE NUMBER STATE ZIP CODE If you have a valid Ohio Disability Placard, submit your current placard number and expiration date. PLACARD NO. EXPIRATION DATE In addition to the signed application and fees all applicants for new or exchange disability license plates must submit an Ohio Certificate of Title Memorandum Title or valid Registration in the name of the current owner/person with disability. EXCHANGE If your vehicle now has regular license plates, you can exchange them for disability license plates. Your regular Ohio license plates will no longer be valid when you receive the disability plates and should be destroyed. Any changes in vehicle ownership, contact your local Deputy Registrar agency or call the Ohio Bureau of Motor Vehicles at 614-752-7800 or 1-800-589-8247. ***OWNERS OF ALTERED VEHICLES, VANS OR BUSES MUST READ THE INSTRUCTIONS AND COMPLETE THE AFFIDAVIT ON THE BACK OF THIS FORM BMV 4834 3/12 Page 1 of 2 RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT FOR MODIFIED/ALTERED VEHICLE OR BUS PRESCRIBED BY THE REGISTRAR OF MOTOR VEHICLES FOR DISABILITY LICENSE PLATES STATE OF OHIO COUNTY OF NAME ON TITLE ADDRESS VEHICLE YEAR VEHICLE MAKE ) ) ) REQUIRED IF DESIGNATED AS A BUS: SEATING CAPACITY GVW CITY STATE ZIP CODE VEHICLE SERIAL NUMBER ALTERED VEHICLE (Passenger, Motor Home, Noncommercial, Motorcycle, House Vehicle). Applicant being duly sworn states that the above described vehicle has been altered to accommodate and transport persons with disabilities. VAN (body type on title must state Van). Applicant being duly sworn states that the above described vehicle has been modified with equipment needed to facilitate the movement of persons with disabilities into and out of the van. The van must be used principally for the transportation of disabled persons. BUS (body type on title must state Bus). Applicant being duly sworn states that the above described vehicle is a bus that will be used principally for transportation of persons with disabilities. Sworn to before me and signed in my presence this (SEAL) day of X X APPLICANT'S SIGNATURE NOTARY PUBLIC MY COMMISSION EXPIRES , An ALTERED VEHICLE is a motor vehicle that has been altered with special equipment to assist a person with disabilities but it is not owned by that person with disabilities. A VAN must be modified with equipment needed to facilitate the movement of persons with disabilities into and out of the van. The van must be used principally for the transportation of persons with disabilities. To qualify for van license plates, the BODY TYPE on the Ohio Title must read VAN. The owner of a BUS used principally for the transportation of persons with disabilities may obtain disability bus license plates. To qualify for bus license plates, the BODY TYPE on the title must read BUS. Disability plates may be ordered through your local Deputy Registrar agency or through the BMV Mail Registration Program. Please allow 10-14 business days from the processing of your application for plates to be received. For additional information, please call the BMV at 1-800-589-TAGS or 614-752-7800. FINES AND PENALTIES In accordance with ORC section 4511.69, any person shall, stop, stand or park any motor vehicle at special parking space locations provided or at special clearly marked parking locations provided in or on privately owned parking lots, parking garages, parking areas and designated for persons with disabilities without the vehicle being operated by or transporting such a person and displaying a disability placard or special license plates is guilty of a misdemeanor. The fine is at least $250.00 but not more than $500.00, is not punishable with imprisonment, and is not a criminal offense. In accordance with ORC 4731.481 and 4734.23, no health care provider shall furnish a prescription to a person to enable the person to obtain a disability placard or special license plate if they do not meet the criteria in ORC section 4503.44. Nor shall any health care provider provide the person with a prescription misrepresenting the expected length of disability. These offenses are misdemeanors of the first degree and are punishable by imprisonment of not more than six months, a fine not more than $1,000, or both, and sanctions by the State Medical Board, the Chiropractic Examining Board or the Board of Nursing respectively. In accordance with ORC section 4503.44, no person or organization shall misrepresent themselves as eligible for a disability placard or special license plates if they are not eligible according to the guidelines of this section. The penalty for this offense is confiscation of the placard or license plates and the revocation of privileges to obtain a disability placard or special license plates. BMV 4834 3/12 Page 2 of 2 RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com
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