Blank NYC disability parking permit PDF Form

Instructions and Application

New York City Special Parking Identification Permit {a.k.a. New York City Parking Permit for People with Disabilities (NYC PPPD)}

To better serve our applicants, the New York City Department of Transportation’s (NYC DOT) Parking Permits for People with Disabilities (PPPD) Unit has put together a list of frequently asked questions that may help guide new applicants through the application process.

How do I know if I am eligible for an NYC Parking Permit for People with Disabilities (NYC PPPD)? Both residents and non-residents of New York City may apply. To be eligible, you must:

•Require the use of a private vehicle for transportation.

•Have a permanent disability that seriously impairs mobility.

What documentation must I provide with an NYC PPPD application?

You are required to provide the following documents with a completed application:

•A copy of the current passenger vehicle registration card for each license plate listed on the application. A photo of the registration sticker will NOT be accepted. Please note that commercial vehicle plates, dealer plates, or plates for a rental vehicle cannot be listed on an NYC PPPD.

•A state-issued driver license, non-driver identification card, or an NYC Municipal ID (IDNYC). Please ensure that the name and address on the application match the name and address on the identification document.

•Medical documentation supporting your disability (dated within one calendar year of the application) from a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.) and certified by a physician designated by the New York City Department of Health and Mental Hygiene (DOHMH). Please note that a Doctor of Podiatric Medicine (D.P.M.) cannot certify the application or submit documentation. Additionally, please note the following:

•The medical documentation must include diagnostic testing/reports in addition to the physician’s legible exam notes. Do not send compact discs (CDs) and X-rays.

•Physician exam notes must document the severity of impairment to your mobility (ability to walk).

•”To Whom it May Concern” or “Dear Doctor“ letters issued by a physician, stating the applicant has a disability, will NOT be accepted.

•For questions regarding medical documentation requirements, please contact the NYC Department of Health and Mental Hygiene’s Medical Certification Unit at 347-396-6552 prior to submitting your application.

What type of vehicle information is required?

Applicants are required to provide a copy of current, valid passenger vehicle registration for each license plate that will be listed on the permit (maximum of three plates). Please do not send photos of a vehicle’s windshield sticker. NYC DOT will not accept any license plate number that has an outstanding parking violation judgment with the New York City Department of Finance (DOF). For more information about outstanding parking violation judgments, please visit the DOF website at

nyc.gov/DOF. Please note, if you plan to list a leased vehicle, you must enclose a copy of the lease agreement for that vehicle.

How should I submit my application?

•Review and sign the application.

•Enclose all information requested on the application form, including supporting medical documentation, and mail your form to:

New York City Department of Transportation

Permits and Customer Service

30-30 Thomson Avenue, 2nd Floor

Long Island City, NY 11101-3045

Please note: An application may also be submitted on behalf of an applicant by a spouse; domestic partner, as defined in the New York City Administrative Code 1-112(21); parent; guardian; or other individual having legal responsibility for the administration of such person’s day-to-day affairs. The name on the application is required to appear exactly as it appears on the identification document. Incomplete applications will be returned.

What will happen after my application is received?

•The PPPD Unit will review all documentation to make sure your application is complete. If the application is considered incomplete, it will be returned to you with a letter describing the missing information needed.

•The PPPD Unit will submit your completed application to DOHMH’s Medical Certification Unit for review. A DOHMH-designated physician will review the application and supporting medical documents. The decision will be based on the information you provide that supports a serious impairment of mobility, as defined in Section 16-02 of Title 24 of the Rules of the City of New York.

•If DOHMH approves your application, the PPPD Unit will issue you a permit.

•If DOHMH denies your application, you will be mailed a letter detailing the appeal process.

•The entire application process may take more than 90 business days.

All information submitted with the application will be kept confidential. Additionally, any subsequent medical documentation submitted to DOHMH will remain confidential. Information submitted will only be shared with those involved in the certification and/or permit process, to the extent allowed or required by law.

If you have any questions regarding this application, you may contact Customer Service at: 718-433-3100. For Teletypewriter (TTY) phone service, call 212-504-4115.

We appreciate the opportunity to serve you and thank you for your cooperation.

New York residents may obtain a Voter Registration Form online at: vote.nyc.ny.us or call the Board of

Elections: 212-868-3692 Phone Bank: 866-VOTE-NYC. Government services are not conditioned on being registered to vote.

MEDICAL HISTORY PAGE

NOTE: TO BE COMPLETED BY YOUR PERSONAL PHYSICIAN (M.D. or D.O.)

Name of Applicant

A DOHMH-designated physician will review the application and supporting medical documents. The decision will be based on the information you provide that supports a serious impairment of mobility, as defined in Section 16-02 of Title 24 of the Rules of the City of New York. Conditions or impairments (Select at least one):

Complete monoplegia or paraplegia of lower extremities.

Above ankle amputation of lower extremities, at the discretion of the examining physician. Well-fitted below the

knee prosthesis with normal ambulatory gait should not routinely be regarded as mobility impaired.

Arthritis of two major weight bearing joints of the lower extremities with clearly substantial X-rays changes and/or MRI changes, such as loss of joint space, severe degenerative changes plus one or more of the following:

(1)Objective finding of sizable effusion of joint(s) detected by clinical examination

(2)Gross instability or valgus/varus deformities of joint(s) detected by clinical examination

(3)Ankylosis or contracture of major joint(s) to such a degree as to preclude stair climbing.

Joint replacement does not qualify by itself unless accompanied by one or more of the above criteria.

Severe atrophy of one or both lower extremities (or discrepancy in leg lengths greater than three inches) which clearly and seriously impairs mobility.

Spinal column abnormalities of severe degree with unequivocal motor involvement not amenable to bracing or surgery which would seriously and permanently impair mobility. X-ray evidence of arthritis of the spine with or without pain is insufficient reason for approval. CT scan, MRI and/or EMG results must be available for review prior to a decision.

Neurological conditions, such as multiple sclerosis, myasthenia gravis, myopathies, Parkinsonism and Alzheimer's Disease, affecting both lower extremities that would seriously impair mobility. Objective documentation (i.e., MRI, EMG, nerve conduction studies, et al.) must be submitted, where appropriate, by the applicant.

Cardiovascular and peripheral vascular disease of severe degree resulting in mobility impairment. Cardiovascular disease must meet AHA Class III or IV criteria; stress test, echocardiogram, Doppler, 6-minute walk test or other diagnostic studies must support evidence of significant pathology and/or disability.

Pulmonary disease with documented evidence of severe obstructive or restrictive disease on pulmonary function testing. Evidence of use of supplemental oxygen for more than twelve hours per day may also be acceptable evidence of impairment.

Renal insufficiency requiring frequent renal dialysis with significant objective finding of neural or hemic abnormalities.

Malignancies of any category that require chemotherapy and/or radiation therapy or other medical interventions which continuously and seriously impair mobility.

Post-Polio syndrome that on examination clearly and seriously impairs mobility.

AIDS related conditions, including peripheral neuropathy, wasting syndrome, dementia, which clearly seriously impair mobility on physical examination.

Mental conditions resulting in intellectual disability of a severe nature documented by appropriate psychological evaluation, which permanently and seriously impair mobility.

Congenital diseases of any type that clearly result in permanent serious mobility impairment, including cerebral palsy, spina bifida and Down syndrome.

Any other permanent disability that in the specific circumstances, would seriously impair the mobility of the applicant, including but not limited to:

Legally blind or severely visual impaired per NY State definition.

Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which imposes an unusual hardship with ambulation and prevents the person from getting around without great difficulty. (please describe)

Mobility Impairments (select at least one):

 Limited ability to walk without assistance. Select all that apply.  Cane  Walker  Wheelchair  Brace

Prosthesis  Scooter  Crutches  Other_____________________

Significant difficulty walking due to severe lung disease.

Unable to walk 200 feet without stopping.

Severe cardiac condition requiring short distances due to inadequate functioning.

Other please describe:________________________________________________________________________

REQUIRED Supporting Medical Documents to include /attach with your application:

Your most recent exam notes/chart notes dated within one (1) calendar year of this application.

Diagnostic testing and imaging reports (e.g. X- Ray report, CT reports, MRI reports, EKG/Stress Test reports, PFT reports, EMG results, Six Minute Walk Test).

DO NOT SEND MEDICAL CDs or FILMS as they will NOT be accepted.

For questions regarding medical documentation requirements please call the NYC Department of Health and Mental Hygiene’s Medical Certification Unit at: 347-396-6552 prior to submitting your application.

In your opinion, does this person have a disability that requires the use of a private automobile for transportation?

Personal Physician’s Certification of the Applicant:

I affirm that I have personally examined the above-named applicant, and that the information presented in this application relating to this person’s disability is accurate.

By signing below, I am certifying that the information I am providing is true and complete, and I understand that any false written statements may be punishable under section 210.45 of the NYS Penal Law and may also be reported to the NYS Department of Health Office of Professional Medical Conduct.

New York City Department of Transportation

NEW YORK CITY SPECIAL PARKING IDENTIFICATION PERMIT

PARKING PERMITS FOR PEOPLE WITH DISABILITIES (PPPD)

CHECKLIST for an NYC PPPD

To ensure completion of your application, please read all instructions on the NYC PPPD application and the Medical History Page.

If all requirements below are not met, your application will be mailed back to you.

Did you attach a copy of your identification document (a state-issued Driver License, Non-Driver Identification Card, or NYC Municipal ID card (IDNYC))?

[See What documentation must I provide with an NYC PPPD application? on Page 1, Instructions]

Did you attach a copy of the passenger vehicle registration for each license plate that would appear on the NYC PPPD? Are they all current (unexpired)?

[See What type of vehicle information is required? on Page 1, Instructions]

Did you make sure the name and address on your application match the name and address on your identification document?

Does the name on your supporting medical documentation match the name listed on your Medical History Page? [See Medical History, Page 4]

Did your physician completely fill out the medical information section, including signing and dating the Medical History Page? [See Medical History, Page 5]

Is all your supporting medical documentation (e.g., Exam Notes/Chart Notes, X- ray/CT/MRI Reports, EKG/Stress Test, consultant reports, etc.) attached? Are all documents dated within one calendar year of your application?

Is your application filled out completely? Did you sign and date the application?