[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306724-105":53,"doc-detail-306724-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","revised-physicians-certification","Revised Physicians Certification","","Arkansas Licensed Provider or Organization Certification form for issuing a special license plate or certificate for persons with disabilities. It provides sections for a certified authority and applicant (Part 1) and, when applicable, for organizations (Part 2), including provider identity details, patient information, and required signatures. The form defines qualifying disability conditions A through L (e.g., mobility limitations, lung disease, portable oxygen, cardiac severity, spinal cord injury) and specifies applicant responsibilities and legal compliance requirements.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/revised-physicians-certification/306724/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/revised-physicians-certification/306724.png","ImageObject",442,249,{"name":88,"@type":89},"วิน","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-26","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who must complete Part 1 of the Arkansas certification form?","Question",{"text":109,"@type":110},"Part 1 is to be completed by a certified authority and the applicant when a Licensed Physician, Physician’s Assistant, Physical Therapist, or Advanced Practice Registered Nurse is certifying an individual.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What disability conditions can qualify a person for the special license plate or certificate?",{"text":114,"@type":110},"The form lists specific qualifying conditions labeled A through L, such as inability to walk 100 feet without stopping, mobility limitations requiring assistance or devices, lung disease with specified spirometry or oxygen criteria, portable oxygen use, cardiac severity, spinal cord injury, genetic ambulatory disorder, amputation, spina bifida, multiple sclerosis, chronic hearing disease, and other conditions.",{"name":116,"@type":107,"acceptedAnswer":117},"What are key legal requirements and consequences for applicants and others?",{"text":118,"@type":110},"Parking privileges apply only when the vehicle is being used to transport the certified person, certificates must be displayed as specified, and providing false information or misusing privileges can result in a Class A misdemeanor, including potential impoundment, fines, towing/impound fees, and possible driver’s license suspension.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306724,1790481995,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336475104736,"https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222","STATE OF ARKANSAS  \nLICENSED PROVIDER OR ORGANIZATION’S CERTIFICATION FOR ISSUANCE OF A SPECIAL LICENSE PLATE OR CERTIFICATE FOR A PERSON WITH A DISABILITY  \nIf a Licensed Physician, Physician’s Assistant, Physical Therapist or Advanced Practice Registered Nurse is certifying an individual, complete Part 1. If an organization providing transportation for persons with a disability with conditions in A through L below, complete Part 2.  \nNotice to Applicant: The department is required to enter into the permanent record disability types in a manner that will allow retrieval of such information for statistical use. The photo ID number or driver’s license number of the person with a disability is necessary to identify and retrieve these statistics.  \nPART 1: TO BE COMPLETED BY A CERTIFIED AUTHORITY AND APPLICANT  \n\n| PRINTED NAME OF PROVIDER: |  |\n| --- | --- |\n| ADDRESS: |  |\n| CITY, STATE, ZIP: |  |\n| PROVIDER’S LICENSE NUMBER ISSUED BY THE ARKANSAS MEDICAL BOARD: |  |\n\n\n| NAME OF PERSON WITH DISABILITY: |  |\n| --- | --- |\n| ADDRESS: |  |\n| CITY, STATE, ZIP: |  |\n| IF TEMPORARY PLACARD: WILL NEED SOCIAL SECURITY NUMBER, DRIVER’S LICENSE NUMBER OR STATE ASSIGNED IDENTIFICATION NUMBER: |  |\n\nI HEREBY CERTIFY THAT THE INDIVIDUAL LISTED ABOVE IS OR HAS BEEN A PATIENT UNDER MY CARE AND IS DISABLED EITHER PERMANENTLY OR TEMPORARILY AS INDICATED BELOW:  \nCIRCLE ONE: PERMANENTLY TEMPORARILY  \nCHECK THE APPROPRIATE BOX OR BOXES A THROUGH L WHICH DEFINES THE PATIENT’S CONDITION(S) .  \n☐ (A) CANNOT WALK ONE HUNDRED (100) FEET WITHOUT STOPPING TO REST:  \n☐ (B) CANNOT WALK WITHOUT THE USE OF ASSISTANCE FROM A BRACE, CANE, CRUTCH, ANOTHER PERSON, PROSTHETIC DEVICE, WHEELCHAIR, OR OTHER ASSISTIVE DEVICE:  \n☐ (C) IS RESTRICTED BY LUNG DISEASE TO SUCH AN EXTENT THAT THE PERSON’S FORCED RESPIRATORY EXPIRATORY VOLUME FOR ONE (1) SECOND, WHEN MEASURED BY SPIROMETRY, IS LESS THAN ONE (1) LITER, OR THE ARTERIAL OXYGEN TENSION IS LESS THAN SIXTY (60) MM/HG ON ROOM AIR AT REST  \n☐ (D) USES PORTABLE OXYGEN  \n☐ (E) 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  \n☐ (F) SPINAL CORD INJURY  \n☐ (G) GENETIC AMBULATORY DISORDER  \n☐ (H) AN AMPUTATION  \n☐ (I) SPINA BIFADA  \n☐ (J) MULTIPLE SCLEROSIS ☐ (K) CHRONIC HEAR DISEASE  \n☐ (L) OTHER:    \nIF NONE OF THE CONDITIONS IN A THROUGH L APPLIES, LIST THE PERMANENT MEDICAL CONDITION THAT SUBSTANTIALLY IMPACTS THE PERSON’S MOBILITY.  \n\n| SIGNATURE OF PROVIDER: | DATE: |\n| --- | --- |\n\nPART 2: TO BE COMPLETED IF APPLICANT IS AN ORGANIZATION  \n\n| NAME OF ORGANIZATION: |  |\n| --- | --- |\n| ADDRESS: |  |\n| CITY, STATE, ZIP |  |\n| FEDERAL EMPLOYER IDENTIFICATION NUMBER: |  |\n\n☐ (M) THIS IS TO CERTIFY THAT THE ORGANIZATION ABOVE OWNS OR LEASES VEHICLES USED PRIMARILY FOR TRANSPORTING PERSONS WITH DISABILITIES AS DEFINED IN ITEMS (A) THROUGH (L) IN PART 1.  \n\n| SIGNATURE OF AUTHORIZED ORGANIZATION OFFICIAL: | DATE: |\n| --- | --- |\n\nAPPLICANTS AND PERSONS DRIVING FOR APPLICANTS WHO REQUEST  \nA SPECIAL LICENSE PLATE OR SPECIAL CERTIFICATE FOR PERSONS WITH A DISABILITY  \nThe following requirements are provided in accordance with Ark. Code Ann. §27-15-307(7) and ACT 98 of 2025.  \n• The privilege to park in spaces reserved for persons with disabilities shall be available only when the vehicle is being used to transport the person for whom the special plate or certificate was issued.  \n• Special certificates must be displayed on the inside rearview mirror, or on the dashboard, if the vehicle is of a type that does not have an inside rearview mirror.  \n• Any individual who provides false information to obtain a special plate or certificate or assists an unqualified person in acquiring a special license plate or special certificate shall be deemed guilty of a Class A misdemeanor.  \n• Any person who abuses the privileges granted by a special license plate or certificate shall be deemed guil","cbCaikIFTFmzQvsf","https://ap.wps.com/l/cbCaikIFTFmzQvsf","pdf",188981,"English","# Part 1: To be Completed by a Certified Authority and Applicant\n## Qualifying disability conditions (A through L)\n# Part 2: To be Completed if Applicant is an Organization\n## Certification for organizations transporting persons with disabilities\n# Applicant requirements and penalties","[{\"question\":\"Who must complete Part 1 of the Arkansas certification form?\",\"answer\":\"Part 1 is to be completed by a certified authority and the applicant when a Licensed Physician, Physician’s Assistant, Physical Therapist, or Advanced Practice Registered Nurse is certifying an individual.\"},{\"question\":\"What disability conditions can qualify a person for the special license plate or certificate?\",\"answer\":\"The form lists specific qualifying conditions labeled A through L, such as inability to walk 100 feet without stopping, mobility limitations requiring assistance or devices, lung disease with specified spirometry or oxygen criteria, portable oxygen use, cardiac severity, spinal cord injury, genetic ambulatory disorder, amputation, spina bifida, multiple sclerosis, chronic hearing disease, and other conditions.\"},{\"question\":\"What are key legal requirements and consequences for applicants and others?\",\"answer\":\"Parking privileges apply only when the vehicle is being used to transport the certified person, certificates must be displayed as specified, and providing false information or misusing privileges can result in a Class A misdemeanor, including potential impoundment, fines, towing/impound fees, and possible driver’s license suspension.\"}]","Revised Physicians Certification | PDF",1789840490]