Form BMV4834 "Health Care Provider Certification of Eligibility for Disability License Plates" - Ohio

What Is Form BMV4834?

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 BMV4834 by clicking the link below or browse more documents and templates provided by the Ohio Department of Public Safety.

ADVERTISEMENT
ADVERTISEMENT

Download Form BMV4834 "Health Care Provider Certification of Eligibility for Disability License Plates" - Ohio

Download PDF

Fill PDF online

Rate (4.7 / 5) 13 votes
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
HEALTH CARE PROVIDER CERTIFICATION OF
ELIGIBILITY FOR DISABILITY LICENSE PLATES
NAME OF APPLICANT
DATE OF BIRTH
DL / ID / SSN OF APPLICANT
ADDRESS
CITY
STATE
ZIP CODE
OHIO REVISED CODE (R.C.) 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,
wheelchair, or other assistive device;
3. Is restricted by a lung 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 sixty millimeters
of mercury on room air at rest;
4. Uses portable oxygen;
5. 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;
6. Is severely limited in the ability to walk due to an arthritic, neurological, or orthopedic condition;
7. A person that is blind, legally blind, or severely visually impaired.
I, X
certify that the above named applicant has
SIGNATURE OF HEALTH CARE PROVIDER
a disability that limits or impairs the ability to walk as defined above by R.C. section 4503.44.
NAME OF HEALTH CARE PROVIDER
LICENSE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
If you have a valid Ohio Disability Placard, submit your current placard number and expiration date.
PLACARD NUMBER
EXPIRATION DATE
In addition to the signed application and fees, all
applicants for new or exchange disability license
I would like to donate $
to the
plates must submit an Ohio Certificate of Title,
Opportunities for Ohioans with Disabilities Agency.
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) 752-7518 or (800) 589-8247.
***OWNERS OF ALTERED VEHICLES, VANS OR BUSES MUST READ THE
INSTRUCTIONS AND COMPLETE THE AFFIDAVIT ON THE BACK OF THIS FORM
RESTRICTED
BMV 4834 10/19 [760-1512] Page 1 of 2
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
HEALTH CARE PROVIDER CERTIFICATION OF
ELIGIBILITY FOR DISABILITY LICENSE PLATES
NAME OF APPLICANT
DATE OF BIRTH
DL / ID / SSN OF APPLICANT
ADDRESS
CITY
STATE
ZIP CODE
OHIO REVISED CODE (R.C.) 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,
wheelchair, or other assistive device;
3. Is restricted by a lung 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 sixty millimeters
of mercury on room air at rest;
4. Uses portable oxygen;
5. 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;
6. Is severely limited in the ability to walk due to an arthritic, neurological, or orthopedic condition;
7. A person that is blind, legally blind, or severely visually impaired.
I, X
certify that the above named applicant has
SIGNATURE OF HEALTH CARE PROVIDER
a disability that limits or impairs the ability to walk as defined above by R.C. section 4503.44.
NAME OF HEALTH CARE PROVIDER
LICENSE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
If you have a valid Ohio Disability Placard, submit your current placard number and expiration date.
PLACARD NUMBER
EXPIRATION DATE
In addition to the signed application and fees, all
applicants for new or exchange disability license
I would like to donate $
to the
plates must submit an Ohio Certificate of Title,
Opportunities for Ohioans with Disabilities Agency.
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) 752-7518 or (800) 589-8247.
***OWNERS OF ALTERED VEHICLES, VANS OR BUSES MUST READ THE
INSTRUCTIONS AND COMPLETE THE AFFIDAVIT ON THE BACK OF THIS FORM
RESTRICTED
BMV 4834 10/19 [760-1512] Page 1 of 2
AFFIDAVIT FOR MODIFIED / ALTERED VEHICLE OR BUS
PRESCRIBED BY THE REGISTRAR OF MOTOR VEHICLES
FOR DISABILITY LICENSE PLATES
NAME ON TITLE
ADDRESS
CITY
STATE
ZIP CODE
VEHICLE YEAR
VEHICLE MAKE
VEHICLE SERIAL NUMBER
SEATING CAPACITY (REQUIRED IF DESIGNATED AS A BUS)
GVW (REQUIRED IF DESIGNATED AS A BUS)
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 persons with disabilities.
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.
APPLICANT SIGNATURE
DATE
X
Notary:
Sworn to and subscribed in my presence this
day of
, 20
in
County,
State of
.
(Notary Seal)
Signature of Notary Public X
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 (614) 752-7518.
FINES AND PENALTIES
In accordance with R.C. 4511.69, no person shall stop, stand, or park a motor vehicle at special clearly marked parking locations
provided in or on privately owned parking lots, parking garages, or parking areas designated for persons with disabilities without the
vehicle being operated by or transporting such person and displaying a disability placard or special license plates. Whoever violates this
section 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 R.C. 4731.481 and 4734.161, no health care provider shall furnish a prescription to a person to enable the person to
obtain a disability placard or special license plates if they do not meet the criteria in R.C. 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 of 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 R.C. 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.
RESTRICTED
BMV 4834 10/19 [760-1512] Page 2 of 2
Page of 2