Medical information means nothing if the individual(s) to which it refers is unidentified...and I don't think the medical particulars are
specified on the original application anyway...only the doctor's name which, again, does not indentify the applicant.
On the contrary, all information is on the form:
http://www.nydmv.state.ny.us/forms/mv6641.pdfLast Name First M.I. Telephone No.
( )
City State Zip Code
Address: No. and Street Apt. No.
Date of Birth
TEMPORARY DISABILITY: A person with a temporary disability is any person who is temporarily unable to ambulate without the aid of an
assisting device. Examples of an assisting device include, but are not limited to, a brace, cane, crutch, prosthetic device, another person,
wheelchair or walker. IMPORTANT: Temporary permits are issued for six months or less regardless of expected recovery date.
Diagnosis:_____________________________________________________
Expected Recovery Date:______________________
What assistive device is needed?_________________________________________________________________________
PERMANENT DISABILITY: A “severely disabled” person is any person with one or more of the PERMANENT impairments,
disabilities or conditions listed below, which limit mobility.
Diagnosis:____________________________________________________ Please check the conditions that apply:
Uses portable oxygen Legally blind Limited or no use of one or both legs Unable to walk 200 ft. without stopping
Neuromuscular dysfunction that severely limits mobility Class III or IV cardiac condition. (American Heart Assoc. standards)
Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
Restricted by lung disease to such an extent that 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 mm/hg of room air at rest
Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which imposes
unusual hardship in the use of public transportation and prevents the person from getting around without great difficulty.
EXPLAIN BELOW HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY.
MD/DO/DPM/NP/PA Name
Professional License No.
Telephone No.
MD/DO/DPM/NP/PA Address