"Application for Nebraska Medical Hardship Permit - Point Revocation" - Nebraska

Application for Nebraska Medical Hardship Permit - Point Revocation is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on January 1, 2012;
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Download "Application for Nebraska Medical Hardship Permit - Point Revocation" - Nebraska

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DMV PROCEDURAL BULLETIN
NEBRASKA MEDICAL HARDSHIP DRIVING PERMIT
WHAT IS THE MEDICAL HARDSHIP PERMIT?
Nebraska State Statute 60-4,130.01 authorized this permit, and it allows a Medical Hardship Driving Permit for
individuals who have forfeited their regular driving privileges under the Point System. The Medical Hardship
Permit would be valid for 90 days, at the expiration of the permit, the driver may reapply for another permit in the
same manner.
This permit can be used to drive from home or place of employment to a hospital, clinic, doctor’s office, or similar
location and return. It cannot be used for shopping, probationary meetings or school.
The issuance of such permit is based upon meeting all appropriate requirements and certification that the use of
the vehicle is required as part of one’s medical hardship and there is no reasonable alternative means of
transportation.
WHO IS ELIGIBLE?
ONLY THOSE INDIVIDUALS WHOSE DRIVING PRIVILEGES HAVE BEEN REVOKED UNDER THE POINT SYSTEM
An individual, who is eligible to be reinstated on any prior suspension/revocation, must be
ARE ELIGIBLE.
reinstated on that suspension/revocation in order to be eligible for a Medical Hardship Driving Permit.
WHAT ARE THE REQUIREMENTS?
(1) An Application for Nebraska Medical Hardship Permit (the application can be downloaded from the
Department of Motor Vehicles website
http://www.dmv.ne.gov
or can be mailed to the driver upon request.
A separate application must be completed for each physician.
(2) Contents of such application form will include: a) General application statement; b) physician affidavit, a
complete affidavit describing the necessity and details of such need; d) an affidavit certifying no alternative
means of transportation.
(3) The application form must be submitted for evaluation and review. In addition, we must receive the revoked
Nebraska Operator’s License (if not already surrendered).
(4) Proof of financial responsibility may be given by one of the following: a) By filing with the Department of Motor
Vehicles, a written certificate of insurance from any insurance company duly authorized to do business in the
State of Nebraska, certifying that there is in effect a motor vehicle liability policy for the benefit of the person
required to furnish the proof of financial responsibility. The certificate of insurance is identified by form SR-22.
We are not permitted to accept your policy or a binder as being the proper identification of your proof of
financial responsibility. b) A Bond of a Surety Company duly authorized to transact business within the State
of Nebraska or a bond with at least two individual sureties who each own real estate within the State of
Nebraska which real estate shall be scheduled in the bond approved by a Judge or a court of record. This
said bond shall be conditioned for the payment of the amounts specified in sub-section 10 in Section 60-501
($75,000.00). c) A Cash bond in the amount of $75,000.00 furnished by a certified check or money order.
THE DIRECTOR OF THE DEPARTMENT OF MOTOR VEHICLES WILL REVOKE THE MEDICAL HARDSHIP
DRIVING PERMIT OF ANY DRIVER CONVICTED OF A VIOLATION FOR WHICH POINTS ARE ASSESSED.
If the permit is revoked in this manner, the individual will not be eligible to receive a Medical Hardship Driving
Permit for the remainder of the period of revocation.
WHERE DO I APPLY AND HOW LONG WILL IT TAKE?
Send requirements to the Department of Motor Vehicles, Medical Hardship Driving Permit Program, P.O. Box
94877, Lincoln, NE 68509-4877. The Department must meet all statutory requirements in review and evaluation
of the application. If requirements are met, the Medical Hardship Drive Permit Authorization letter will be issued
for the driver to present to the Driver License Examiner.
Printed with soy ink on recycled paper
REV 01/03/2012
DMV PROCEDURAL BULLETIN
NEBRASKA MEDICAL HARDSHIP DRIVING PERMIT
WHAT IS THE MEDICAL HARDSHIP PERMIT?
Nebraska State Statute 60-4,130.01 authorized this permit, and it allows a Medical Hardship Driving Permit for
individuals who have forfeited their regular driving privileges under the Point System. The Medical Hardship
Permit would be valid for 90 days, at the expiration of the permit, the driver may reapply for another permit in the
same manner.
This permit can be used to drive from home or place of employment to a hospital, clinic, doctor’s office, or similar
location and return. It cannot be used for shopping, probationary meetings or school.
The issuance of such permit is based upon meeting all appropriate requirements and certification that the use of
the vehicle is required as part of one’s medical hardship and there is no reasonable alternative means of
transportation.
WHO IS ELIGIBLE?
ONLY THOSE INDIVIDUALS WHOSE DRIVING PRIVILEGES HAVE BEEN REVOKED UNDER THE POINT SYSTEM
An individual, who is eligible to be reinstated on any prior suspension/revocation, must be
ARE ELIGIBLE.
reinstated on that suspension/revocation in order to be eligible for a Medical Hardship Driving Permit.
WHAT ARE THE REQUIREMENTS?
(1) An Application for Nebraska Medical Hardship Permit (the application can be downloaded from the
Department of Motor Vehicles website
http://www.dmv.ne.gov
or can be mailed to the driver upon request.
A separate application must be completed for each physician.
(2) Contents of such application form will include: a) General application statement; b) physician affidavit, a
complete affidavit describing the necessity and details of such need; d) an affidavit certifying no alternative
means of transportation.
(3) The application form must be submitted for evaluation and review. In addition, we must receive the revoked
Nebraska Operator’s License (if not already surrendered).
(4) Proof of financial responsibility may be given by one of the following: a) By filing with the Department of Motor
Vehicles, a written certificate of insurance from any insurance company duly authorized to do business in the
State of Nebraska, certifying that there is in effect a motor vehicle liability policy for the benefit of the person
required to furnish the proof of financial responsibility. The certificate of insurance is identified by form SR-22.
We are not permitted to accept your policy or a binder as being the proper identification of your proof of
financial responsibility. b) A Bond of a Surety Company duly authorized to transact business within the State
of Nebraska or a bond with at least two individual sureties who each own real estate within the State of
Nebraska which real estate shall be scheduled in the bond approved by a Judge or a court of record. This
said bond shall be conditioned for the payment of the amounts specified in sub-section 10 in Section 60-501
($75,000.00). c) A Cash bond in the amount of $75,000.00 furnished by a certified check or money order.
THE DIRECTOR OF THE DEPARTMENT OF MOTOR VEHICLES WILL REVOKE THE MEDICAL HARDSHIP
DRIVING PERMIT OF ANY DRIVER CONVICTED OF A VIOLATION FOR WHICH POINTS ARE ASSESSED.
If the permit is revoked in this manner, the individual will not be eligible to receive a Medical Hardship Driving
Permit for the remainder of the period of revocation.
WHERE DO I APPLY AND HOW LONG WILL IT TAKE?
Send requirements to the Department of Motor Vehicles, Medical Hardship Driving Permit Program, P.O. Box
94877, Lincoln, NE 68509-4877. The Department must meet all statutory requirements in review and evaluation
of the application. If requirements are met, the Medical Hardship Drive Permit Authorization letter will be issued
for the driver to present to the Driver License Examiner.
Printed with soy ink on recycled paper
REV 01/03/2012
Financial Responsibility Division
Medical Hardship Driving Permit Program
301 Centennial Mall South, P.O. Box 94877
Lincoln, Nebraska 68509-4877
(402) 471-3985 Fax (402) 471-8288
APPLICATION FOR NEBRASKA MEDICAL HARDSHIP PERMIT – POINT REVOCATION
Items A – E below must be completed and sent to the Financial Responsibility Division at the address
1
listed above. If the application is properly completed and you are eligible, you will be sent a letter
authorizing you to go to a Driver Examining Station to be issued the Medical Hardship Driving Permit.
Must be a Nebraska resident, have tested and been issued a license (Provisional Operator’s Permit holders are
A.
not eligible for the Medical Hardship Drive Permit).
B.
Current Nebraska Operator’s License – if not already surrendered;
Properly completed SR-22 Certificate of Insurance from your insurance company (application, binder or
C.
insurance card will not be accepted);
D.
This completed application form. You will need a separate application for each doctor you have; and,
Comply with all reinstatement requirements for any suspensions/revocations in Nebraska or any other state
E.
that prohibits you from obtaining the Medical Hardship Drive Permit.
The Authorization Letter for Issuance of Medical Hardship Drive Permit is based upon you, the
NOTE:
driver, meeting all conditions. If any of the above requirements are not met, you will not be issued
the Authorization Letter.
Provide Personal Information (Please Print)
2
nd
rd
Last Name
First Name
Middle Initial
Suffix (Jr., Sr., 2
, 3
)
Current Residential Address (Cannot accept a mailing address or P.O. Box)
City
State
Zip Code
Date of Birth
Home Phone Number
Social Security Number
Month
Day
Year
Providing you are eligible, upon receipt of all applicable requirements, you will be sent a letter
authorizing you to appear before a Driver License Examiner to obtain the Nebraska Medical Hardship
Drive Permit. Authorization is based on meeting all conditions including certification that the use of a
vehicle is a requirement for your medical treatment and there is no reasonable alternative means of
transportation. The Medical Hardship Drive Permit is valid for 90 days and you must apply for renewal
if still needed after the expiration date.
By si g n i n g t h i s ap p l i ca t i o n I sw e ar o r af f i r m t h at :
I certify that I will notify the Department of Motor Vehicles of change or termination of treatment. If I
3
change treatment, I must immediately contact the Department of Motor Vehicles to file a revised
application in reference to my new treatment schedule in order to maintain my Medical Hardship Drive
Permit privileges. I understand that my permit will not be valid until there is a properly completed
application on file for my treatment.
Please initial
By initialing this statement, I agree and understand that failure to notify the Department
of any change in my treatment will cause my Medical Hardship Driving Permit to
immediately become null and void.
I understand that the Director of the Department of Motor Vehicles will revoke the Medical Hardship
4
Drive Permit upon receipt of the abstract of conviction indicating that I committed an offense for which
points are assessed and I will not be eligible to receive a Medical Hardship Drive Permit for the
remainder of the period of revocation of my operator’s license or privilege to drive.
Please initial
By initialing this statement, I understand that if I commit any violation where points are
assessed my Medical Hardship Driving Permit will be revoked.
Medical Information:
5
Place of treatment:
Describe the nature of your
medical treatment:
Days/Hours – detailed information is required for your protection. If you are stopped
driving after the permit has been issued, law enforcement will refer to the application
6
you submitted for verification of the days/hours of your treatment.
):
Days of treatment (please
days required
(√)
(√)
(√)
(√)
(√)
(√)
(√)
MON
TUE
WED
THUR
FRI
SAT
SUN
Hours of scheduled treatment. Please include driving time:
Leave home at:
am
pm
Return home at:
am
pm
Routes/Areas of travel - detailed information is required for your protection. If you are
stopped driving after the permit has been issued, law enforcement will refer to the
7
application you submitted for verification of your Routes/Areas of travel.
Bus Routes:
Other:
Briefly describe other transportation options available:
Yo u m u st si g n t h i s ap p li cat i o n i n t h e p r e se n ce o f a No t ar y Pu b li c:
State of
8
County of
Applicant’s Signature
The signature of the Applicant was acknowledged before me this
day of
,
.
Printed name
Notary Public Signature
Seal
Date:
Physician’s Affidavit
9
Your patient is making application for a Nebraska Medical Hardship Drive Permit. State law requires, as one of the
conditions for issuance for such permit, that the physician sign an affidavit swearing to the validity of the claim that
the use of a vehicle is required in traveling to and from his or her place of treatment and/or in the course of the
applicant’s medical needs.
Your assistance is appreciated.
Patient’s (Applicant’s) Name:
Street Address
City / State / Zip Code
Patient’s (Applicant’s) Address:
Medical Facility information
10
Name of the Medical Facility:
Street Address
City / State / Zip Code
Facility Address:
Name
Phone Number
Physician’ Name / Phone number:
I can confirm the need for my patient to drive as a condition of his/her
11
medical needs as described below:
Please circle
I can confirm the need for my patient to drive as a condition of his/her medical needs.
1.
Yes
No
Please circle
2.
I can confirm that treatment will not impair the applicant’s ability to operate a motor vehicle.
Yes
No
Please circle
3.
The days/hours of travel my patient listed in Section 6 are correct.
Yes
No
Please circle
The routes/areas of travel my patient listed in Section 7 are correct.
4.
Yes
No
You must sign the application in the presence of a Notary Public:
Signature below must be same as Physician’s Name provided in
Section 10 above.
State of
12
County of
Physician’s Signature
The signature of the Physician was acknowledged before me
this
Printed name
day of
,
.
Notary Public Signature
Seal
Date:
The Medical Hardship Drive Permit cannot be used to operate a commercial motor
NOTE:
vehicle or as a commercial driver’s license.
APPLICATION FOR EMPLOYMENT DRIVING PERMIT
REV 01/01/2012
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