The Arkansas 10 336 form is crucial for residents who are looking to file specific types of insurance claims within the state. It serves as a formal document to initiate the claim process, ensuring that all necessary information is captured accurately and comprehensively. If you're ready to get started, click the button below to fill out your form today.
Nestled in the realm of regulatory compliance and operational adherence within the state of Arkansas, the Arkansas 10 336 form emerges as a pivotal document. This form, integral to various procedural undertakings, encapsulates the essence of meticulous record-keeping and regulatory compliance, serving as a bridge between entities and the governing bodies overseeing them. It's designed to streamline processes, ensure accuracy in data reporting, and uphold the integrity of operations across multiple domains. As part of its wide-ranging functionality, the form touches upon essential metrics, data collection, and submission protocols, thereby standing as a cornerstone in the administrative framework that facilitates smooth operational flow. Through its structured format, it not only aids in fulfilling statutory requirements but also provides a systematic approach for entities to present their compliance with established norms and practices. Thus, understanding the nuances of the Arkansas 10 336 form is crucial for entities operating within the state, ensuring they remain aligned with legal expectations and contribute to a transparent, accountable, and efficient regulatory environment.
STATE OF ARKANSAS
LICENSED PHYSICIAN’S OR ORGANIZATION’S CERTIFICATION FOR ISSUANCE
OF A SPECIAL LICENSE PLATE OR CERTIFICATE FOR A PERSON WITH A DISABILITY
If a licensed physician 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.
Notice 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.
PART 1: TO BE COMPLETED BY A LICENSED PHYSICIAN AND APPLICANT (UNLESS APPLICANT IS AN ORGANIZATION)
Name of Physician:
Address:
City State Zip:
Name of Person with Disability:
If Temporary Placard need Social Security Number, Driver’s
License Number or State Assigned Identification Number:
I 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.
CIRCLE ONE:
PERMANENTLY
TEMPORARILY
Check the appropriate box or boxes A through L, which defines the patient’s condition(s).
(A) Cannot walk one hundred (100) feet without stopping to rest;
(B)
Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or
other assistive device;
(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;
(D) Uses portable oxygen;
(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;
(F)
Spinal cord injury;
(G)
Genetic ambulatory disorder;
(H)
An amputation;
(I)
Spina bifida;
(J)
Multiple Sclerosis;
(K)
Chronic heart disease;
(L)
Other:______________________________________________________________________________________________
If none of the conditions in A through L above applies, list the permanent medical condition that substantially impacts the person’s mobility.
Signature of Physician:
Date
PART 2: TO BE COMPLETED IF APPLICANT IS AN ORGANIZATION
Name of Organization:
Federal Employer Identification Number:
(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.
Signature of Authorized Organization Official:
IMPORTANT NOTICE ON BACK
10-336
10/07
APPLICANTS AND PERSONS DRIVING FOR APPLICANTS WHO REQUEST
A SPECIAL LICENSE PLATE OR SPECIAL CERTIFICATE FOR PERSONS WITH A DISABILITY
The following requirements are provided in accordance with Ark. Code Ann. §27-15-307(7).
•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.
•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.
•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.
•Any person who abuses the privileges granted by a special license plate or certificate shall be deemed guilty of a Class A misdemeanor.
•Any unauthorized vehicle found to be parked in an area designated for the exclusive use of a person with a disability shall be subject to impoundment by the appropriate law enforcement agency. In addition to impoundment, the owner of the vehicle shall upon conviction be subject to fine of not less than one hundred dollars ($100) nor more than five hundred dollars ($500) for the first offense, nor less than two hundred fifty dollars ($250) nor more one thousand dollars ($1000) for the second and subsequent offense, plus applicable towing, impoundment, and related fees as well as court costs. Upon the second or subsequent conviction, the court shall suspend the driver’s license for up to six (6) months. The driver may apply to the Office of Driver Services of the Arkansas Department of Finance and Administration for a restricted license during the period of suspension.
•If a person to whom a special certificate or license plate has been issued moves to another state, the person shall surrender the special certificate or plate to the nearest Revenue Office.
•If a person to whom a special certificate or license plate has been issued dies, the special certificate or license plate shall be returned to the Revenue Office within thirty (30) days after the death of the person to whom the special certificate or plate was issued.
•The special certificate issued for the permanently disabled shall expire four (4) years from the last day of the month in which it was issued. The applicant shall not be required to obtain re-certification of his qualifying disability in order to renew his special certificate.
•The special temporary certificate shall expire three (3) months from the last day of the month in which it was issued.
Filling out the Arkansas 10 336 form is a necessary step for individuals who need to submit it for their specific needs. Carefully completing this form ensures all the required information is accurately provided, facilitating a smoother process for the concerned parties. Below is a detailed guide outlining each step to fill out the form properly. After the form is filled, it should be reviewed for any mistakes, signed where necessary, and then submitted following the instructions provided by the relevant Arkansas department.
Remember, the Arkansas 10 336 form is an important document, and attention to detail when filling it out is crucial. Once the form is duly filled, signed, and submitted, it will be processed accordingly. Keep a copy of the completed form for your records.