Form PA-3 "Disability Parking Permit Application" - Hawaii

What Is Form PA-3?

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

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Hawaii Department of Health;
  • 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 fillable version of Form PA-3 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

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Download Form PA-3 "Disability Parking Permit Application" - Hawaii

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PERSON WITH A DISABILITY PARKING PERMIT APPLICATION FORM
INSTRUCTION SHEET (FORM PA-3)
SIDE 1 – TO BE COMPLETED BY APPLICANT
1.
APPLICANT INFORMATION. Print or type your name, beginning with your first name, middle initial, then last
name. Only include a suffix (Jr., Sr., III, etc.) if applicable.
2.
PHONE NUMBER. Print your telephone number, including the area code. If you do not have a telephone
number, write “NONE.”
3. EMAIL ADDRESS. Enter your email address if you have one. This is optional. DCAB will use it ONLY to contact
you for parking program purposes.
4. DATE OF BIRTH. Print the month, day and year. Example: If your date of birth is June 30, 1965, you
would print 06/30/1965.
5. HEIGHT. Print your height in feet and inches.
6. WEIGHT. Print your weight in pounds.
7. GENDER. Mark the box for either Male or Female.
8. MAILING ADDRESS. Print your mailing address.
9. INDICATE THE COUNTY WHERE YOU LIVE. Answer only if you live in Hawaii. Mark the box next to the
county where you reside. Mark one box only.
10. PARKING PLACARD REQUEST. Mark the box next to the type of placard you are requesting.
First time application. Mark this box if this is the first time that you are applying for a temporary (red)
placard, long term (blue) placard, Disability Paid Parking Exemption Permit/DPPEP (green) placard, or
special license plates. A temporary (red) placard will be valid for no more than 6 months. There is a $12 fee
for a temporary (red) placard. There is no fee for a first time long term (blue) placard or a first time DPPEP
(green) placard.
Second placard. Mark this box if you want a second temporary (red) placard. A second temporary (red)
placard is an additional placard that has the same expiration date as its companion placard. There is a $12
fee for a second temporary (red) placard.
Renewing placard. Mark this box to renew your temporary (red) placard, long term (blue) placard, or
Disability Paid Parking Exemption Permit/DPPEP (green) placard. You may apply up to 60 days before it
expires. Print the placard number of your expiring or expired placard(s) in the space provided. Check your
blue I.D. card for your placard number(s). If you currently have two temporary (red) placards and want two
renewal temporary (red) placards, enter the placard number of each expiring or expired placard in the
spaces provided. There is a $12 fee for renewing each temporary (red) placard. There is no fee to renew a
long term (blue) placard or Disability Paid Parking Exemption Permit/DPPEP (green) placard. YOU MUST
ALSO HAVE YOUR DISABILITY RECERTIFIED BY A LICENSED PRACTICING PHYSICIAN/ADVANCED
PRACTICE REGISTERED NURSE (APRN).
Replacing a confiscated, lost, stolen, or mutilated temporary (red) placard or long term (blue) placard.
Mark this box if your temporary (red) placard or long term (blue) placard was confiscated, lost, stolen, or
mutilated and is still valid. Print the placard number(s) in the space provided. Check your blue I.D. card for
the placard number(s). There is a $12 fee for replacing a confiscated, lost, or stolen temporary (red) placard
or long term (blue) placard. There is no fee for replacing a mutilated placard, but you must bring in its
remaining parts, otherwise, it will be treated as replacing a lost placard and a $12 fee will apply. Side 2 of
the form should be left blank.
Replacing a confiscated, lost, or stolen Disability Paid Parking Exemption Permit/DPPEP (green)
placard. Mark this box if your DPPEP (green) placard was confiscated, lost, or stolen and is still valid. Print
the placard number in the space provided. Check your blue I.D. card for the placard number. The
replacement fees are as follows: first replacement $30, second replacement $60, third replacement $90,
and any subsequent replacement $120. Side 2 of the form should be left blank.
Replacing a mutilated Disability Paid Parking Exemption Permit/DPPEP (green) placard. There is no fee
for replacing a mutilated DPPEP (green) placard that is still valid. You must mail in its remaining parts,
otherwise, it will be treated as replacing a lost placard and a fee will apply. Side 2 of the form should be left
blank.
11. SPECIAL LICENSE PLATES REQUEST. Mark only if requesting Special License Plates. You must provide
information where indicated. You may obtain one set of plates and one long term (blue) placard or one Disability
Paid Parking Exemption Permit/DPPEP (green) placard.
12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. Read the information
carefully. This is your statement that you understand the terms of using the placard or special license plates.
Sign and date the statement. If you are unable to sign due to your disability, your authorized representative may
sign on your behalf.
Form PA-3 Instruction Sheet
1 of 2
PERSON WITH A DISABILITY PARKING PERMIT APPLICATION FORM
INSTRUCTION SHEET (FORM PA-3)
SIDE 1 – TO BE COMPLETED BY APPLICANT
1.
APPLICANT INFORMATION. Print or type your name, beginning with your first name, middle initial, then last
name. Only include a suffix (Jr., Sr., III, etc.) if applicable.
2.
PHONE NUMBER. Print your telephone number, including the area code. If you do not have a telephone
number, write “NONE.”
3. EMAIL ADDRESS. Enter your email address if you have one. This is optional. DCAB will use it ONLY to contact
you for parking program purposes.
4. DATE OF BIRTH. Print the month, day and year. Example: If your date of birth is June 30, 1965, you
would print 06/30/1965.
5. HEIGHT. Print your height in feet and inches.
6. WEIGHT. Print your weight in pounds.
7. GENDER. Mark the box for either Male or Female.
8. MAILING ADDRESS. Print your mailing address.
9. INDICATE THE COUNTY WHERE YOU LIVE. Answer only if you live in Hawaii. Mark the box next to the
county where you reside. Mark one box only.
10. PARKING PLACARD REQUEST. Mark the box next to the type of placard you are requesting.
First time application. Mark this box if this is the first time that you are applying for a temporary (red)
placard, long term (blue) placard, Disability Paid Parking Exemption Permit/DPPEP (green) placard, or
special license plates. A temporary (red) placard will be valid for no more than 6 months. There is a $12 fee
for a temporary (red) placard. There is no fee for a first time long term (blue) placard or a first time DPPEP
(green) placard.
Second placard. Mark this box if you want a second temporary (red) placard. A second temporary (red)
placard is an additional placard that has the same expiration date as its companion placard. There is a $12
fee for a second temporary (red) placard.
Renewing placard. Mark this box to renew your temporary (red) placard, long term (blue) placard, or
Disability Paid Parking Exemption Permit/DPPEP (green) placard. You may apply up to 60 days before it
expires. Print the placard number of your expiring or expired placard(s) in the space provided. Check your
blue I.D. card for your placard number(s). If you currently have two temporary (red) placards and want two
renewal temporary (red) placards, enter the placard number of each expiring or expired placard in the
spaces provided. There is a $12 fee for renewing each temporary (red) placard. There is no fee to renew a
long term (blue) placard or Disability Paid Parking Exemption Permit/DPPEP (green) placard. YOU MUST
ALSO HAVE YOUR DISABILITY RECERTIFIED BY A LICENSED PRACTICING PHYSICIAN/ADVANCED
PRACTICE REGISTERED NURSE (APRN).
Replacing a confiscated, lost, stolen, or mutilated temporary (red) placard or long term (blue) placard.
Mark this box if your temporary (red) placard or long term (blue) placard was confiscated, lost, stolen, or
mutilated and is still valid. Print the placard number(s) in the space provided. Check your blue I.D. card for
the placard number(s). There is a $12 fee for replacing a confiscated, lost, or stolen temporary (red) placard
or long term (blue) placard. There is no fee for replacing a mutilated placard, but you must bring in its
remaining parts, otherwise, it will be treated as replacing a lost placard and a $12 fee will apply. Side 2 of
the form should be left blank.
Replacing a confiscated, lost, or stolen Disability Paid Parking Exemption Permit/DPPEP (green)
placard. Mark this box if your DPPEP (green) placard was confiscated, lost, or stolen and is still valid. Print
the placard number in the space provided. Check your blue I.D. card for the placard number. The
replacement fees are as follows: first replacement $30, second replacement $60, third replacement $90,
and any subsequent replacement $120. Side 2 of the form should be left blank.
Replacing a mutilated Disability Paid Parking Exemption Permit/DPPEP (green) placard. There is no fee
for replacing a mutilated DPPEP (green) placard that is still valid. You must mail in its remaining parts,
otherwise, it will be treated as replacing a lost placard and a fee will apply. Side 2 of the form should be left
blank.
11. SPECIAL LICENSE PLATES REQUEST. Mark only if requesting Special License Plates. You must provide
information where indicated. You may obtain one set of plates and one long term (blue) placard or one Disability
Paid Parking Exemption Permit/DPPEP (green) placard.
12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. Read the information
carefully. This is your statement that you understand the terms of using the placard or special license plates.
Sign and date the statement. If you are unable to sign due to your disability, your authorized representative may
sign on your behalf.
Form PA-3 Instruction Sheet
1 of 2
SIDE 2 – TO BE COMPLETED BY A PHYSICIAN OR ADVANCED PRACTICE REGISTERED NURSE
ONLY IF SIDE 1 IS COMPLETED FIRST
13. (Required) CERTIFICATION OF CONDITION. To qualify for a disability parking permit, the physician or
Advance Practice Registered Nurse (APRN) must certify that the applicant has a disability that limits or impairs
the ability to walk 200 feet without stopping to rest and has been diagnosed with at least one of the conditions
listed in (A) AND at least one of the functional impacts of the condition in (B).
Do not provide certification unless at least one condition listed in (A) and at least one condition listed in
(B) is true as it pertains to the applicant.
NOTE: Under (B), certifying that the applicant cannot walk 200 feet without stopping to rest means the
applicant cannot walk 200 feet under the applicant's own power without stopping to rest.
The following conditions do not qualify: visual impairments; mental illness; old age; infancy; deafness; upper
limb amputation; pregnancy; behavioral, learning, intellectual or developmental disabilities.
14. (Required) DURATION OF DISABILITY. Mark the box that corresponds to the expected duration of the
qualifying disability. If the expected duration is less than six years, mark the box next to the month of the
expected duration on the Temporary line. Subsequent certifications can be made if the disability lasts longer
than six months. If the disability is expected to last a minimum of six years, mark the 6 years box on the Long
Term line.
15. (Optional) UNABLE TO APPLY IN PERSON. Mark only if the applicant is unable to apply in person due to a
medical condition.
16. (Required) PHYSICIAN/APRN CERTIFICATION. Input the following information:
Print physicianʻs/APRNʻs full name, phone number and mailing address.
Input medical license number (must be a Hawaii license unless military stationed in Hawaii).
Circle medical license type (only listed types are accepted).
Signature and date (apply to date of certification). A digital signature is accepted. A fax or photocopy of the
physicianʻs/APRNʻs signature will NOT be accepted.
17. (Optional) CERTIFICATION FOR DISABLED PAID PARKING EXEMPTION PERMIT/DPPEP.
Certification is appropriate under this section only if the applicant has (1) a valid driverʻs license and (2) one of
the three conditions listed is true as it pertains to the applicant. Do not certify if the applicant does not
qualify. If certifying the applicant for a DPPEP, full completion of sections 16 and 17 is required.
GIVE COMPLETED ORIGINAL FORM BACK TO APPLICANT. MAY RETAIN A COPY FOR MEDICAL FILE.
______________________________________________________________________
WHERE TO SUBMIT THE COMPLETED APPLICATION
First Time and Replacement of Temporary (red) and Long term (blue) Placards; Renewal of Temporary (red)
Placards, and Special License Plates Applications.
Applicant must submit this form to a county issuing site. If the Physician/APRN certifies that the applicant is unable
to appear in person because of a medical condition (see section 15 on Side 2), the applicantʻs authorized
representative must present the applicant’s original I.D. along with the completed application form. A fax or
photocopy of the applicantʻs completed form will NOT be accepted.
Renewal of a Long Term (blue) Placard.
Completed original form must be mailed to:
DCAB
P.O. Box 3377
Honolulu, HI 96801
First Time, Replacement, or Renewal of a Disabled Paid Parking Exemption Permit/DPPEP (green) Placard.
Completed original form, a copy of the applicantʻs valid driver’s license, and payment if the application is for a
replacement DPPEP placard, must be mailed to:
DCAB
P.O. Box 3377
Honolulu, HI 96801
Form PA-3 Instruction Sheet
2 of 2
STATE OF HAWAII • DISABILITY AND COMMUNICATION ACCESS BOARD
DISABILITY PARKING PERMIT APPLICATION
FOR OFFICIAL USE ONLY
Applicant must present valid I.D. or if mailing the form, attach a legible copy. In lieu of an I.D., a notarized affidavit
may be attached from: a Hawaii State or County social service agency, the administrator of a Hawaii State or
First Placard #
private nursing home, the spouse, an adult relative, a friend, an assistant, the certifying physician or advanced
practice registered nurse (APRN). If certifying physician or APRN completes section 17, attach a copy of
Second Placard #
the applicant’s valid unexpired driver’s license.
Expiration Date
SUBMITTING THIS FORM:
First time application for a temporary (red), long term (blue) placard, or special license plates; or
License Plates #
renewing a temporary (red) placard – submit form and valid I.D. to a County issuing site.
Replacing a confiscated, lost, stolen, or mutilated temporary (red) or long term (blue) placard – submit
FEES COLLECTED, IF APPLICABLE
form, valid I.D., and a $12 payment to a County issuing site. No payment required for mutilated
placards that are submitted to a County issuing site.
Amount Collected $
Renewing an expiring long term (blue) placard – mail form to: DCAB, P.O. Box 3377, Honolulu, HI 96801.
Disabled paid parking exemption permit (DPPEP) (green) for first time, renewing, or replacing – mail
Clerk’s Initials
Date
form and a copy of valid driver’s license to: DCAB, P.O. Box 3377, Honolulu, HI 96801. For
DPPEP application, #16 and #17 must be completed by physician/APRN.
APPLICANT INFORMATION (Please print or type clearly)
1. FIRST NAME
LAST NAME
SUFFIX
MIDDLE INITIAL
2. PHONE NUMBER
3. EMAIL ADDRESS (optional)
4. DATE OF BIRTH (mm/dd/yyyy)
5. HEIGHT (Feet, Inches)
6. WEIGHT (Pounds)
7. GENDER
Male
Female
8. MAILING ADDRESS
APT #
CITY
STATE
ZIP CODE
9. INDICATE THE COUNTY WHERE YOU LIVE
City & County of Honolulu
County of Hawaii
County of Kauai
County of Maui
10. PARKING PLACARD REQUEST
First time application (placards and special license plates)
Second placard (only available for temporary (red) placard)
Renewing placard #
Second placard (if any) #
Replacing a confiscated, lost, stolen, or mutilated temporary (red) or long term (blue) parking placard #
Replacing a confiscated, lost, or stolen DPPEP (green) placard # E
*First replacement $30 / Second replacement $60 / Third replacement $90 / Subsequent replacements $120
Mail application with check or money order made payable to: Department of Health
Replacing a mutilated DPPEP (green) placard # E
(include placard with form)
11. COMPLETE ONLY IF REQUESTING SPECIAL LICENSE PLATES (DP)
I currently have special license plates. DP #
I am requesting special license plates. I am the registered owner of the vehicle on which the special license plates will be
affixed, AND the vehicle will be used primarily to transport me.
Year of Vehicle
Make
Model
Vehicle Lic. #
Vehicle Registration Expiration Date
12. DECLARATION AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION. I declare, under the penalties of the penal law, that the
statements contained herein are, to the best of my knowledge and belief, true and accurate, and that I have not knowingly and willingly made a false
statement or given information which I know to be false in connection therewith. I authorize DCAB to contact the email address listed in #3 if
provided. I also authorize my physician or advanced practice registered nurse to release medical information necessary to process this application.
APPLICANT SIGNATURE (or Authorized Representative)
Date (mm/dd/yyyy)
FORM PA-3
SIDE 1
PHONE: 808-586-8121
WEB: www.health.hawaii.gov/dcab
JULY 2021
CERTIFICATION BY LICENSED PRACTICING PHYSICIAN/APRN
All sections on this page must be completed by a licensed practicing physician (as defined under Hawaii Revised Statutes (HRS) §§453, 455,
460, or 463E) or an advanced practice registered nurse (APRN) (as defined under HRS §457). The physician or APRN must certify that the applicant
(1) has a disability that limits or impairs the ability to walk and (2) has one or more of the specific disabilities listed under items A and B (as defined
under HRS §291-51). Individuals who belong to any of the following classes do not qualify for a permit based solely on that status: persons who
have a visual impairment; persons who have a mental illness; persons who are old; persons who are infants; persons who are deaf; persons who
have an upper limb amputation; persons who are pregnant; and persons who have a behaviorial, learning, intellectual, or developmental disability.
13. CERTIFICATION OF CONDITION (must check at least one box in (A) and at least one box in (B)):
I certify that applicant name:
has a disability that limits or impairs the ability to walk and has been
diagnosed with one of the following conditions:
(A) (i)
Arthritic
Neurological
Orthopedic
Oncologic
Renal
Vascular
(ii) LUNG DISEASE:
FEV < 1L – Forced (respiratory) expiratory volume for one second, when measured by spirometry, is less
than one liter.
P3O2 < 60 mm/hg – Arterial oxygen tension is less than sixty mm/hg on room air at rest.
(iii) CARDIAC CONDITION according to the American Heart Association Standards:
Class III – Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest.
Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV – Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.
Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physicial
AND
activity is undertaken discomfort is increased.
(B) Because of the condition identified in #13A, the applicant (must check at least one):
Cannot walk 200 feet without stopping to rest
Cannot walk (under his/her own power) without the use of, or assistance from, the following:
Artificial Lower Limb(s)
Brace(s)
Crutches
Walker
Cane(s) (excluding white cane)
Another Person
Wheelchair
Other Assistive Device (specify):
Uses portable oxygen
14. DURATION OF DISABILITY:
Mark one box only. If the disability lasts longer than anticipated, subsequent certification can be made.
1 month
2 months
3 months
4 months
5 months
6 months
Temporary
6 years (only check if disability is expected to last a minimum of 6 years)
Long Term
15. APPLICANT IS UNABLE TO APPLY IN PERSON (Mark only if applicable)
I certify that this applicant is physically unable to apply in person due to a medical condition.
Physician/APRN Signature
16. REQUIRED.
PHYSICIAN/APRN CERTIFICATION. I understand that per HRS §291-51.4, a physician/APRN, who fraudulently verifies that the
applicant is qualified for purposes of this form shall be guilty of a petty misdemeanor and each fraudulent verification shall constitute a separate
offense. DCAB conducts random checks to verify the authenticity of certifications.
FIRST NAME
LAST NAME
MI
PHONE NUMBER
MAILING ADDRESS
CITY
ZIP CODE
HI
MEDICAL LIC. NO.
CIRCLE ONE:
MD / MDR / ND / DOS / DOSR / PO / APRN
(Hawaii or U.S. Armed Services
Stationed in Hawaii)
PHYSICIAN/APRN SIGNATURE
DATE (mm/dd/yyyy)
17. OPTIONAL. CERTIFICATION FOR DISABLED PAID PARKING EXEMPTION PERMIT: COMPLETE ONLY IF APPLICANT
QUALIFIES. To qualify, applicant MUST have (1) a VALID DRIVER’S LICENSE, (2) a mobility disability described in #13(A) and
#13(B) above, and (3) one of the conditions below. I, physician/APRN, certify that: (check at least one)
The applicant cannot reach above the applicant’s head to a height of 42 inches from the ground due to a lack of finger,
hand, or upper extremity strength or mobility;
The applicant cannot approach a parking meter due to the use of a wheelchair or other mobility device; or
The applicant cannot manage, manipulate, and insert coins, bills, or cards in a parking meter or pay station due to a
lack of fine motor control in both hands.
FIRST NAME
LAST NAME
MI
PHONE NUMBER
MAILING ADDRESS
CITY
ZIP CODE
HI
MEDICAL LIC. NO.
CIRCLE ONE:
MD / MDR / ND / DOS / DOSR / PO / APRN
(Hawaii or U.S. Armed Services
Stationed in Hawaii)
PHYSICIAN/APRN SIGNATURE
DATE (mm/dd/yyyy)
FORM PA-3
SIDE 2
PHONE: 808-586-8121
WEB: www.health.hawaii.gov/dcab
JULY 2021