Form BMV5755 "Health Care Provider Certification of Eligibility for Permanently Disabled Identification Card" - Ohio

What Is Form BMV5755?

This is a legal form that was released by the Ohio Department of Public Safety - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Ohio Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form BMV5755 by clicking the link below or browse more documents and templates provided by the Ohio Department of Public Safety.

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Download Form BMV5755 "Health Care Provider Certification of Eligibility for Permanently Disabled Identification Card" - Ohio

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OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
HEALTH CARE PROVIDER CERTIFICATION OF ELIGIBILITY
FOR PERMANENTLY DISABLED IDENTIFICATION CARD
SECTION A – CUSTOMER INFORMATION
FULL LEGAL NAME
DATE OF BIRTH
DL / ID / SSN OF APPLICANT
ADDRESS
CITY
STATE
ZIP CODE
A resident who is eligible for an identification card with expiration dates that is in accordance with division (A)(8)(b) of
section 4507.52 of the R.C. and who is currently unemployed may apply for the issuance of an identification card under
this section without payment of any fee, including any document processing fees.
I am currently unemployed:
Yes
No
SECTION B – HEALTH CARE PROVIDER CERTIFICATION
NAME OF HEALTH CARE PROVIDER
LICENSE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
OHIO REVISED CODE (R.C.) SECTION 4507.50 and 4507.52 STATES IN PART THAT: Any non-driver identification
card that is issued to a resident of Ohio who is permanently or irreversibly disabled must be issued with an eight (8)
year expiration date and to exempt such cardholders who are also unemployed from the identification card fees. The
disability must be confirmed by a physician or health care provider:
I, X
on __________
certify that the above named
SIGNATURE OF HEALTH CARE PROVIDER
DATE
applicant is permanently or irreversibly disabled, with no present indication of recovery as defined above by R.C. section 4507.52(b).
By completing this form, I am hereby affirming that ALL of the requirements of section 4507.50 and 4507.52 have been met and
that all the information contained on this form is true and accurate. I understand that providing false information may constitute a
criminal offense of falsification under section 2921.13 of the R.C. and is a misdemeanor of the first degree.
SIGNATURE OF APPLICANT
DATE
X
NOTE: This document is valid for 30 days from the date indicated by the Heath Care Provider.
BMV 5755 10/19 [760-1491]
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
HEALTH CARE PROVIDER CERTIFICATION OF ELIGIBILITY
FOR PERMANENTLY DISABLED IDENTIFICATION CARD
SECTION A – CUSTOMER INFORMATION
FULL LEGAL NAME
DATE OF BIRTH
DL / ID / SSN OF APPLICANT
ADDRESS
CITY
STATE
ZIP CODE
A resident who is eligible for an identification card with expiration dates that is in accordance with division (A)(8)(b) of
section 4507.52 of the R.C. and who is currently unemployed may apply for the issuance of an identification card under
this section without payment of any fee, including any document processing fees.
I am currently unemployed:
Yes
No
SECTION B – HEALTH CARE PROVIDER CERTIFICATION
NAME OF HEALTH CARE PROVIDER
LICENSE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
OHIO REVISED CODE (R.C.) SECTION 4507.50 and 4507.52 STATES IN PART THAT: Any non-driver identification
card that is issued to a resident of Ohio who is permanently or irreversibly disabled must be issued with an eight (8)
year expiration date and to exempt such cardholders who are also unemployed from the identification card fees. The
disability must be confirmed by a physician or health care provider:
I, X
on __________
certify that the above named
SIGNATURE OF HEALTH CARE PROVIDER
DATE
applicant is permanently or irreversibly disabled, with no present indication of recovery as defined above by R.C. section 4507.52(b).
By completing this form, I am hereby affirming that ALL of the requirements of section 4507.50 and 4507.52 have been met and
that all the information contained on this form is true and accurate. I understand that providing false information may constitute a
criminal offense of falsification under section 2921.13 of the R.C. and is a misdemeanor of the first degree.
SIGNATURE OF APPLICANT
DATE
X
NOTE: This document is valid for 30 days from the date indicated by the Heath Care Provider.
BMV 5755 10/19 [760-1491]