PHYSICIAN S CERTIFICATION OF TOTAL AND PERMANENT DISABILITY I Physician s name DR-416 R. 11/12 Rule 12D-16. 002 Florida Administrative Code Effective 11/12 a physician licensed pursuant to Chapter 458 or Chapter 459 Florida Statutes hereby certify that Mr. Miss Ms. Name of totally and permanently disabled person Social Security Number is totally and permanently disabled as of January 1 due to the following mental or physical condition s Quadriplegia Paraplegia Hemiplegia Legal blindness Other to.
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How to fill out the FL DR-416 online
Completing the FL DR-416 form is an essential step for residents applying for a total and permanent disability exemption in Florida. This guide will provide you with concise instructions on filling out the form online, ensuring that you accurately convey the necessary information.
Follow the steps to complete the FL DR-416 form effectively.
- Press the ‘Get Form’ button to access the FL DR-416 document and open it in your preferred editing interface.
- In the first section, enter the physician's name. This section certifies the physician's endorsement of the disability claim.
- Next, you will need to check the appropriate box that reflects the status of the individual being certified, with options such as Mr., Mrs., Miss, or Ms., followed by the full name of the person who is totally and permanently disabled.
- Provide the social security number of the individual listed. This information is obligatory and is used for verification purposes.
- Indicate the effective date of the disability, which is stated as January 1. Additionally, specify the nature of the total and permanent disability by checking the relevant condition(s), such as quadriplegia, paraplegia, hemiplegia, legal blindness, or any other condition requiring a wheelchair for mobility.
- If applicable, check the box stating that the patient is totally and permanently disabled but does not require a wheelchair for mobility. This distinction is important for the certification process.
- The physician should provide their signature and the date of signature to validate the certification. Ensure that the signature is legible.
- Lastly, complete the address section by including the street, city, state, and zip code where the physician practices. Don't forget to include the Florida Board of Medicine or Osteopathic Medicine license number and the date it was issued.
- Once all sections are duly completed, you can save your changes, download the form, print it, or share it as needed.
Start filling out the FL DR-416 online today to submit your application for the total and permanent disability exemption.
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