Eligibility Check - ProviderNotes

1
Type a question
2
Will you be in Florida for your video visit?* This field is required.
Yes
No
3
Are you applying for a Florida disabled parking permit? (Also called a handicap placard, tag, or sticker)* This field is required.
Yes
No
4
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)
5
Has your recent procedure affected your ability to walk more than 200 feet without resting?* This field is required.
Yes
No
6
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
7
Which state do you need a disabled parking permit for?
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
I'm not applying for a parking permit
8
It looks like you may need a Florida permit after all. Florida is the state we currently serve. Would you like to continue with the Florida eligibility check?
Please Select
Yes, continue with the Florida eligibility check
No, I need something else
9
Want us to let you know if we begin serving your state?
Please Select
Yes, email me if Provider Notes becomes available in my state
No thanks
10
Email addressWe'll only use this to tell you if we begin serving your state. Nothing else.
example@example.com
11
What is your current gestational age in weeks?* This field is required.
12
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
13
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
14
What's your full name?* This field is required.
First Name
Last Name
15
What's your email?* This field is required.
example@example.com
16
What's your phone number?* This field is required.
Please enter a valid phone number.
17
Outcome
Should be Empty: