Free Bfs 108 Michigan Template Prepare Document Here

Free Bfs 108 Michigan Template

The BFS 108 Michigan form is a Disability Parking Placard Application used by Michigan residents who have a qualifying disability. This document requests necessary personal and medical information to assess eligibility for a disability parking placard. It requires completion and certification from a healthcare professional and, if applicable, additional information for organizations providing transport services to individuals with disabilities. Need to apply for a disability parking placard? Click the button below to get started.

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The BFS 108 Michigan form is a vital document for individuals and organizations in Michigan seeking to obtain disability parking placards. This form serves as an application for disability parking placards and includes sections for personal information, medical eligibility certification, and, if applicable, a request for free parking based on specific eligibility criteria. The Michigan Department of State mandates the completion of this form, with parts requiring accurate information from the applicant and a detailed medical certification from a healthcare provider, such as a physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant. The form contains guidelines on who qualifies for a disability placard, the criteria for free parking eligibility, and the application process for organizations providing transportation services for disabled persons. Penalties for misuse or fraudulent application are clearly outlined, emphasizing the importance of integrity in the application process. Furthermore, the form facilitates communication between applicants and the Michigan Department of State, ensuring that those with legitimate needs have access to parking accommodations that can significantly improve their quality of life.

Sample - Bfs 108 Michigan Form

Placard Number:

MICHIGAN DEPARTMENT OF STATE

 

Disability Parking Placard Application

Office Use Only:

 

Expiration

 

Date:

Directions:

Applicants please complete and sign Part 1. Your physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant must complete Part 2 and the certification on the bottom of this page. If you also qualify for free parking, your physician, chiropractor, optometrist, nurse practitioner, or physician’s assistant

must also complete Part 3. Organizations applying for parking placards to provide transportation services for disabled persons complete Part 4. Completed applications may be presented at any Secretary of State branch office or mailed to the address on the reverse side of this form.

(Application cannot be processed without signed release of information and physician’s certification)

Part 1: Release of Information and Signature

I am applying for a disability parking placard as provided in Public Act 300 of 1949. I authorize the release of the medical information described below to the Michigan Department of State. I certify the information is true and realize by making a false statement on this application I am subject to the penalties described on the reverse side of this form.

(Please print)

Name (First, Middle, Last)

 

 

 

 

 

 

Date of Birth

Michigan Drivers License or ID Card #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

County

 

Disability Plate Number (if any)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

 

 

 

 

Daytime Phone Number

Last Parking Permit Number

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

Do you have a CDL endorsement?

If yes, do you have a medical

waiver?

 

Are you a Michigan resident?

YES

 

 

NO

 

 

YES

 

 

NO

If yes, attach copy of waiver

YES

 

NO

 

 

Signature of Disabled Person

 

 

 

 

 

 

 

 

Date

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Representative (If presented by representative)

 

 

 

 

 

Representative’s Driver License Number

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 2: Medical Eligibility Standards and Physician’s Determination

The Michigan Vehicle Code [MCL 257.19a] states that a disabled person be determined by a licensed physician, physician’s assistant, chiropractor, nurse practitioner, or optometrist identifying one or more of the following characteristics which affect your patient’s ability to walk.

Circle all letters that apply

Right Eye:

Left Eye:

Both Eyes:

Visual field (in degrees):

a) Blindness. Corrected acuity level:

20/______

20/______

20/______

____________

b)An inability to walk more than 200 feet without having to stop and rest. Please provide the diagnosis for this ambulatory disability:_______________________________________________________________________________________

c)Patient must use a wheelchair, walker, crutch, brace, or other ambulatory aid to walk.

Describe:_______________________________________________________________________________________

d)Patient has a lung disease from which the forced expiratory volume for one second, when measured by spirometry, is less than one liter, or from which the arterial oxygen tension is less than 60mm/hg of room air at rest.

e)Patient has a cardiovascular condition which measures between 3 and 4 on the New York Heart Classification Scale, or which renders the patient incapable of meeting a minimum standard for cardiovascular health established by the American Heart Association and approved by the Michigan Department of Public Health.

f)Patient has an arthritic, neurological, or orthopedic condition that severely limits ability to walk.

Describe: _______________________________________________________________________________________

g)Patient has a persistent reliance upon an oxygen source other than ordinary air.

Physician’s Certification

 

A parking placard will be issued solely on the physician’s evaluation

 

 

 

 

 

 

Patient’s condition is: Permanent

 

Temporary

 

 

If temporary, estimated duration: ______months (maximum 6 months)

 

 

 

 

 

 

 

 

 

 

Physician’s Name

 

Medical Specialty

Office Telephone

 

 

 

 

 

 

 

Street Address

 

City, State, Zip

 

Office Fax

I certify the person listed above is eligible for a disability placard as provided in Public Act 300 of 1949. I also understand that making a false statement to obtain a disability parking placard is a misdemeanor and may result in fines, imprisonment, or both.

Physician’s Signature

X

(Physician / Chiropractor / Physician’s Assistant / Optometrist / Nurse Practitioner)

Medical License Number *

Date

*If the medical license was issued in a state other than Michigan, the physician must submit a copy of their medical license.

BFS-108 (05/13) NOTE: If the individual listed above is also eligible for free parking, Part 3 on the reverse side of this application must also be completed.

Part 3: Free Parking Application And Physician’s Certification

The free parking application is completed only when the applicant qualifies for free parking. To qualify, your patient must be a Michigan licensed driver, have an ambulatory disability described in Part 2, and also have one of the following conditions. Economic need is not a consideration.

Circle all letters that apply:

a)The patient cannot insert coins or tokens in a parking meter or cannot accept a ticket from a parking lot machine due to a lack of fine motor control of both hands.

b)The patient cannot reach above their head to a height of 42 inches from the ground, due to a lack of finger, hand, or upper extremity strength or mobility.

c)The patient cannot approach a parking meter due to use of a wheelchair or other ambulatory device.

d)The patient cannot walk more than twenty feet due to an orthopedic, cardiovascular, or lung condition in which the degree of debilitation is so severe that it almost completely impedes the patient’s ability to walk. (A condition requiring applicant to rest after walking twenty feet when not using a wheelchair or other ambulatory device.)

I certify the person listed on the front of this application is also eligible for free parking as provided in state law [MCL 257.675]. I under- stand that making a false statement to obtain a free parking sticker is a misdemeanor and may result in fines, imprisonment, or both.

Physician’s signature: X

 

Date

 

 

(Physician / Chiropractor / Physician’s Assistant / Optometrist / Nurse Practitioner)

 

_________________________________________________________________________________________________

Part 4: Organization Request For Disability Parking Placards

(Please print)

Name of Organization

County

Telephone Number

( )

Street Address

City, State, Zip

Describe the transportation services your organization provides to persons with disabilities:

Number of disability placards you are requesting: ________ (No more then 1 per vehicle used to transport clients.)

I am applying for a disability parking placard as provided in Public Act 300 of 1949 and certify the above information is true.

Signature of Organization Officer

Printed Name of Organization Officer

Date

X

 

 

Organization Officer’s Driver License Number

Position (Title) with Organization

 

 

 

 

Note: If the organization ceases to provide specialized services to disabled persons, the parking placard must be returned to the Secretary of State for cancellation.

__________________________________________________________________________________________________

Penalties

Michigan Vehicle Code Section 257.675 Prohibits:

Using a disability parking placard to park in a designated parking space unless the disabled person is driving or being transported.

Altering, modifying, or selling a disability parking placard or free parking sticker.

Copying or forging, or using a copied or forged disability parking placard or free parking sticker.

Making a false statement to obtain a disability parking placard or free parking sticker, or committing a deception or fraud on a medical statement attesting to a disability.

Knowingly using or displaying a disability parking placard that has been canceled by the Secretary of State.

A violation is a misdemeanor and punishable by a fine up to $500 or imprisonment for up to 30 days, or both. A law enforcement officer may immediately confiscate a disability parking placard for improper use.

__________________________________________________________________________________________________

Return completed applications to any

Michigan Department of State

Secretary of State branch office or mail to:

Out-of-State Resident Services Unit

 

PO Box 30764

 

Lansing, MI 48918

If you have any questions regarding disability parking placards, please call 1-888-767-6424.

Authority granted under Pubic Act 300 of 1949, as amended.

File Details

Fact Name Description
Form Title BFS 108 Michigan Disability Parking Placard Application
Governing Law Public Act 300 of 1949
Eligibility Criteria A licensed physician, physician’s assistant, chiropractor, nurse practitioner, or optometrist must certify the applicant has a qualifying condition affecting their ability to walk.
Placard Duration Placards can be issued as either permanent or temporary, with temporary placards valid for a maximum of 6 months.
Free Parking Eligibility Applicants may also qualify for free parking if they meet specific criteria related to physical disabilities and are Michigan licensed drivers.

Bfs 108 Michigan - Usage Steps

Filling out the BFS 108 Michigan form is essential for individuals seeking a disability parking placard in Michigan. This form must be completed accurately to ensure compliance with the Michigan Department of State's requirements. The process involves sections that must be filled out by the applicant and part of it by a certified health professional. Here are the steps to correctly complete the form:

  1. Part 1: Release of Information and Signature
    • Enter your full name (first, middle, last), date of birth, and Michigan Driver's License or ID Card number.
    • Provide your street address, including city, state, zip code, and county.
    • If applicable, fill in your disability plate number and last parking permit number.
    • Indicate whether you possess a CDL endorsement and if a medical waiver is attached by marking the appropriate box.
    • Confirm your Michigan residency status by marking 'Yes' or 'No'.
    • Enter your daytime phone number.
    • Sign and date the form at the X. If the application is submitted by a representative, they must sign and provide their driver license number in the designated area.
  2. Part 2: Medical Eligibility Standards and Physician’s Determination
    • This section is to be completed by a licensed physician, physician’s assistant, chiropractor, nurse practitioner, or optometrist.
    • They must circle all applicable conditions that apply to the applicant’s ability to walk.
    • The medical professional must fill out their name, medical specialty, office address, telephone, and fax numbers.
    • They must indicate whether the patient's condition is permanent or temporary. If temporary, the estimated duration (not exceeding 6 months) should be specified.
    • A signature from the medical professional and their medical license number, along with the date, are required.
    • If the medical license was issued outside of Michigan, a copy of the license must be included.
  3. Part 3: Free Parking Application And Physician’s Certification
    • This part is only completed if the applicant qualifies for free parking.
    • The certifying medical professional must circle any conditions that apply from the listed options that qualify the applicant for free parking.
    • A signature from the certifying medical professional, along with the date, must be provided.
  4. Part 4: Organization Request For Disability Parking Placards
    • This section is applicable only if an organization is applying to provide transportation services for disabled persons.
    • Provide the name of the organization, county, telephone number, and address.
    • Briefly describe the transportation services offered to persons with disabilities.
    • Indicate the number of disability placards you are requesting for your organization (limit of 1 per vehicle used to transport clients).
    • An organization officer must sign and date this part, also including their driver license number and position with the organization.

Once all relevant parts of the BFS 108 Michigan form are completed, it can be submitted to any Secretary of State branch office in Michigan or mailed to the address provided on the form. The form provides individuals and organizations the ability to apply for the necessary disability parking placards in compliance with state regulations. Complete accuracy and honesty in application are paramount to avoid any legal repercussions.

Learn More on This Form

What is the BFS-108 Michigan form used for?

The BFS-108 form is an application for a disability parking placard in Michigan. It allows individuals with specific disabilities to apply for a placard that permits parking in designated disability parking spaces. The form is also used by organizations that provide transportation services to disabled persons, allowing them to apply for parking placards.

Who is eligible to apply for a disability parking placard?

Eligibility for a disability parking placard includes individuals who have one or more of the following conditions as certified by a licensed physician, physician's assistant, chiropractor, nurse practitioner, or optometrist:

  • Blindness
  • An inability to walk more than 200 feet without stopping to rest
  • A requirement to use an ambulatory aid
  • Severe lung disease
  • A cardiovascular condition as described in the form
  • Arthritic, neurological, or orthopedic condition that severely limits one's ability to walk
  • Reliance on portable oxygen

How can one apply for the disability parking placard?

To apply for the disability parking placard, the applicant must complete Part 1 of the BFS-108 form, and a medical professional must complete Part 2, certifying the disability. If applicable, Part 3 must be filled out to apply for free parking. Organizations must complete Part 4 for their placards. The completed form can then be submitted to any Secretary of State branch office or mailed to the specified address on the form.

Is there a temporary disability parking placard available?

Yes, temporary disability parking placards are available for individuals with temporary disabilities. The medical professional certifying the application will indicate whether the condition is permanent or temporary and, if temporary, the estimated duration of the condition (up to a maximum of 6 months).

How does one qualify for free parking with a disability parking placard?

To qualify for free parking, the applicant must have an ambulatory disability (as certified in Part 2 of the form) and meet one of the additional conditions listed in Part 3. These conditions include the inability to insert coins into parking meters due to fine motor control loss, inability to reach or operate parking equipment, or severe mobility impairments that restrict the individual's capacity to access parking meters.

What should one do if the provided information changes or the placard is no longer needed?

If there's a change in the disability status or if a placard is lost, stolen, or no longer needed, the individual or organization must notify the Michigan Department of State. If the placard is no longer required, it should be returned to the Secretary of State for cancellation to avoid misuse or potential penalties.

What are the penalties for misuse of a disability parking placard?

Penalties for misuse of a disability parking placard include fines up to $500, imprisonment for up to 30 days, or both. Misuses include parking in a disability space without the disabled person present, altering or selling placards, using a placard that has been canceled, or making false statements to obtain a placard. Law enforcement may confiscate placards if they're found to be misused.

Common mistakes

Filling out the BFS 108 Michigan form, which is required for obtaining a disability parking placard, presents several common pitfalls that can lead to the rejection or delay of an application. Understanding these mistakes is essential to streamline the application process and ensure applicants receive their necessary accommodations without unnecessary hurdles.

  1. Not thoroughly completing Part 1: A frequent mistake is leaving sections of Part 1 incomplete. This part of the form requires personal information, including the applicant's name, date of birth, driver's license or ID card number, and contact details. It's crucial that every field is filled out accurately. Neglecting to provide complete information, such as the Michigan Driver’s License or ID Card #, can result in the application being returned or delayed.

  2. Omitting the signature of the disabled person or representative: Another common error is failing to sign the application. The signature of the disabled person or their representative at the bottom of Part 1 is mandatory for the application to be processed. This signature is a form of consent, authorizing the release of medical information to the Michigan Department of State and certifying the truthfulness of the information provided.

  3. Inadequate details in Part 2 regarding the medical condition: Part 2 of the form must be completed by a licensed physician, physician’s assistant, chiropractor, nurse practitioner, or optometrist. Applicants sometimes submit forms with vague or insufficient details about the medical eligibility standards and the physician’s determination. Specific details about how the applicant's condition affects their ability to walk, along with clear certification of the disability's permanence or temporary nature, are required for the reviewing committee to make an informed decision.

  4. Overlooking Part 3 for applicants eligible for free parking: Often, applicants who qualify for free parking due to severe mobility impairments miss completing Part 3. This section is critical for those who have significant difficulties with parking meters or machines due to their condition. Ensuring that the healthcare provider accurately identifies and circles the applicable conditions and signs the certification is essential for applicants to avail of the free parking benefit.

Applicants and healthcare providers must pay close attention to the specifics when completing the BFS 108 Michigan form. Accurate completion of all sections, providing detailed descriptions of the disability, and including all necessary signatures are fundamental steps in receiving a disability parking placard. By avoiding these mistakes, applicants can help ensure their applications are processed efficiently and without unnecessary delays.

Documents used along the form

When dealing with disability accessibility and legal documentation in Michigan, understanding the array of forms and documents that complement the BFS 108 Michigan form is crucial. This comprehensive guide explores several essential forms often used alongside the BFS 108 form to facilitate smoother processes for individuals seeking disability accommodations.

  • Michigan Driver's License Application (Form DL-1P): This form is a key document for any Michigan resident applying for a driver's license. It's essential for residents who may also be applying for a disability parking placard as it verifies their identity and residency.
  • Vision Specialist's Statement (Form DI-4V): A pivotal document for individuals whose disability involves visual impairment. This form, completed by a certified vision specialist, provides detailed information regarding an individual's eyesight and its implications on their driving capabilities.
  • Medical Evaluation Request (Form DI-4P): In certain scenarios where medical conditions may affect driving abilities, this form is filled out by a healthcare provider. It outlines the medical condition and its potential impact on driving, helping the Department of State assess a person's driving capabilities.
  • Request for Hearing (Form SOS-257/258): If there's a dispute or a need for a formal discussion regarding the issuance of a disability parking placard or any related matter, this form initiates the hearing process within the Department of State.
  • Change of Address (Form SOS-272): It's crucial to keep address information up to date. This form ensures that any correspondence or legal documentation, including disability parking placards, is sent to the correct address.
  • Disability Certification by School Psychologist (Form BFS-103): Specifically designed for school-aged individuals, this form allows a school psychologist to certify a disability, which can be part of the broader documentation needed for mobility or other accommodations.
  • Physician's Statement of Certification (Form BFS-124): Similar to part 2 of the BFS 108 form, this document is a more detailed certification by a physician or qualified medical professional, outlining an individual's medical condition and the necessity for disability accommodations.
  • Organization Vehicle Placard Application (Form BFS-450): For organizations serving individuals with disabilities, this form enables the application for vehicle placards, facilitating transportation needs.
  • Temporary Disability Parking Placard Application (Form BFS-108T): For short-term disabilities, this variant of the BFS 108 form allows for the application of temporary parking accommodations, ensuring individuals have access to necessary support during their temporary impairment.

Each document plays a pivotal role in ensuring individuals with disabilities receive the appropriate accommodations and support. Whether it's applying for a driver's license, verifying a medical condition, or requesting a hearing, these forms collectively work to streamline the process and uphold the rights of individuals with disabilities in Michigan.

Similar forms

The BFS 108 Michigan form, designed for Disability Parking Placard Applications, is inherently detailed to cater to those with varying degrees of mobility challenges. This form is foundational in providing individuals and organizations the necessary certification for disability parking, underscoring its importance in promoting accessibility and compliance with state laws.

One document similar to the BFS 108 Michigan form is the ADA Application for Parking Placard/License Plate available in many states. Both documents serve a crucial role in identifying individuals with disabilities and granting them special parking privileges. The similarity extends to the need for medical certification to validate the disability claim, ensuring that the privileges are granted to those genuinely in need. The ADA forms, much like the BFS 108, often require detailed personal information, a physician's certification, and sometimes, additional specifics regarding the nature and extent of the disability. Such forms are pivotal in ensuring that the process of allocating parking privileges is both fair and regulated.

Another document that shares similarities with the BFS 108 form is the Application for Disabled Person Parking Permit used in many jurisdictions. Like the BFS 108, this application typically necessitates detailed personal information, the signature of a healthcare provider to verify the disability, and an outline of the criteria that qualify an individual for the permit. The structure of these documents underscores a universal approach to assessing and identifying the needs of individuals with disabilities, aiming to provide them with the necessary accommodations to enhance their mobility and quality of life.

Each document, while similar in purpose to the BFS 108 Michigan form, is tailored to meet the legal and procedural requirements specific to its jurisdiction. These forms collectively reflect a broader commitment to accessibility and support for individuals with disabilities, ensuring they have the necessary means to navigate public spaces with dignity and ease.

Dos and Don'ts

Filling out the BFS 108 Michigan form for a disability parking placard requires careful attention to detail and an understanding of the application process. To ensure your application is processed smoothly and without delay, here are some dos and don'ts to keep in mind:

Do:

  • Double-check all personal information for accuracy, including your name, date of birth, Michigan Drivers License or ID Card number, and contact information. Mistakes can lead to unnecessary delays or problems with your application.
  • Ensure that Part 2 is fully completed by the appropriate medical professional (physician, chiropractor, nurse practitioner, etc.) who is certified to assess your condition. This part is crucial for determining your eligibility, and missing or incomplete information could result in your application being rejected.
  • Sign and date Part 1 of the form to authorize the release of your medical information to the Michigan Department of State. An unsigned application is considered incomplete and will not be processed.
  • Attach a copy of your medical waiver if you have a CDQ endorsement and answered "yes" to having a medical waiver. This documentation is required for processing your application.

Don't:

  • Leave any sections blank. If a question or section does not apply to you, write "N/A" to indicate this. Blank sections can cause confusion and may lead to your application being held up.
  • Forget to include contact information for your physician or the medical professional who completes Part 2. The Secretary of State may need to contact them for further verification or clarification.
  • Alter any part of the form after it has been completed, especially after the medical professional has filled out Part 2. Altering forms can lead to mistrust and potential legal issues.
  • Attempt to submit the application without the necessary signatures. Both your signature and that of the medical professional are required to validate the application and the information within it.

By following these dos and don'ts, you can help ensure that your application for a disability parking placard in Michigan is completed correctly and processed in a timely manner. Remember to consult the Michigan Department of State or call the provided helpline if you have any questions or require assistance with your application.

Misconceptions

Understanding the BFS 108 Michigan form, specifically regarding disability parking placards, is crucial for those applying. However, misconceptions can lead to confusion. Here are four common misunderstandings about the form and its requirements:

  • Misconception 1: Free Parking: It's often thought that if you qualify for a disability parking placard, you automatically qualify for free parking. The truth is, additional criteria must be met and documented in Part 3 of the form by a medical professional. These criteria focus on specific physical limitations regarding the use of parking meters or receiving tickets from a machine.
  • Misconception 2: Physician's License: Another common mistake is the belief that only Michigan-based physicians can sign off on the BFS 108 form. While the form does indeed require a medical professional's certification, out-of-state physicians, chiropractors, nurse practitioners, or optometrists can also complete it, provided they supply a copy of their medical license with the application.
  • Misconception 3: Permanent Conditions Only: Some think that only individuals with permanent disabilities are eligible for a parking placard. However, the form allows for the issuance of placards to those with temporary disabilities as well, as indicated by the medical professional in Part 2. The duration of the temporary condition can be specified up to a maximum of six months.
  • Misconception 4: Organizations and Free Parking: There's a misconception that organizations providing transportation services for persons with disabilities, applying through Part 4, can also apply for free parking on behalf of those individuals. In reality, free parking eligibility is strictly determined based on the individual’s condition and abilities as treated and documented by the medical professional in Part 3, not the organization applying on someone's behalf.

Clearing up these misconceptions can ease the application process for a disability parking placard in Michigan, ensuring applicants provide all necessary information accurately and according to state guidelines.

Key takeaways

Filling out and using the BFS-108 form for a Michigan disability parking placard requires understanding several key aspects to ensure proper completion and adherence to the state's regulations. Here are four critical takeaways:

  • Both applicant and medical professional roles are clearly defined within the application process. Applicants must complete Part 1, including the release of information and their signature, while a physician, chiropractor, optometrist, nurse practitioner, or physician's assistant is responsible for completing Part 2 and the certification. For applicants eligible for free parking, the medical professional must also complete Part 3.
  • The form stipulates specific medical conditions that qualify an individual for a disability parking placard. These range from visual impairments and the inability to walk more than 200 feet without stopping for rest, to reliance on an oxygen source other than ordinary air. Thus, having a clear understanding of these conditions is essential for both the applicant and the certifying medical professional.
  • Organizations providing transportation services to persons with disabilities can apply for parking placards by completing Part 4. This section requires detailed information about the organization and the specialized transportation services it offers, emphasizing the form's applicability beyond individual use.
  • It is critical to acknowledge the legal ramifications associated with the BFS-108 form. Making false statements during the application process is a misdemeanor subject to fines, imprisonment, or both. Additionally, the misuse of a disability parking placard, such as using it in designated spaces without transporting the disabled person or altering, copying, or forging placards, is strictly prohibited and punishable under Michigan law.

Proper completion and submission of the BFS-108 form to the Michigan Department of State, along with adherence to the guidelines and legal requirements, ensure that individuals and organizations providing for persons with disabilities can obtain and use parking placards effectively and within the bounds of the law.

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