Eligibility Check - ProviderNotes

1

Are you physically located in Florida right now?* This field is required.

Yes

No

2

Are you applying for a Florida disabled parking permit (placard)?* This field is required.

Yes

No

3

What's the main reason you have difficulty walking? Pick the option that best describes your main condition. If multiple conditions apply, pick the one that most limits your walking.* This field is required.

Joint, back, spine, or musculoskeletal problem (arthritis, herniated disc, spinal stenosis, sciatica, joint replacement, post-surgical recovery, chronic back/neck/hip/knee pain, whiplash, fibromyalgia)

Heart or lung condition (heart failure, COPD, severe asthma, pulmonary disease)

Whole-body neurological condition (stroke recovery, multiple sclerosis, Parkinson's disease, ALS, brain injury)

Vision impairment (legally blind, severe vision loss)

Recent surgery or anesthesia recovery (gallbladder, appendix, joint replacement, hernia, abdominal surgery, or any procedure affecting endurance)

Pregnancy with significant mobility limitation

Something else (we'll ask for details on the next step)

4

Has your recent procedure affected your ability to walk more than 200 feet without resting?* This field is required.

Yes

No

5

Please describe your condition and why you believe it qualifies you for a Florida disabled parking permit. Be specific - your doctor reads this before your visit.* This field is required.Include: what your condition is called (if known), how long you've had it, and how it limits your walking. Example: "I have rheumatoid arthritis in my knees. Diagnosed 5 years ago. I can walk about 50 feet before needing to rest."

0/500

6

What is your current gestational age in weeks?* This field is required.

7

How much does your condition limit your walking?* This field is required.

Significantly - I have substantial difficulty walking even short distances or need to stop frequently

Sometimes - my walking is limited during flare-ups, weather changes, or specific situations

Minimally - I can walk normally most of the time without significant limitation

8

Are you applying because of a real medical need (not just for convenience)?* This field is required.

Yes - I have a real medical need

No - I'm applying for convenience reasons

9

What's your full name?* This field is required.

First Name

Last Name

10

What's your email?* This field is required.

example@example.com

11

What's your phone number? (optional)

Please enter a valid phone number.

12

Outcome

13

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