The Physician Certification Form is a State of Mississippi Department of Public Safety (DPS) form that a licensed physician completes to certify a driver's diabetes, hearing impairment or qualifying disability. The Driver Service Bureau uses it to place a symbol on a driver license or ID card, or to issue a disability identification card. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the official PDF is published by the Mississippi Driver Service Bureau.
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What is Physician Certification Form – Mississippi?
The Physician Certification Form is the one-page State of Mississippi Department of Public Safety form on which a licensed physician certifies that a patient has diabetes, is hearing impaired or has a disability, so that the Driver Service Bureau can add the matching symbol or issue a disability ID.
The Driver Service Bureau's page describes it as the form used to have a symbol placed on a driver license (DL) or on an individual's ID card to show that the person is diabetic, hearing impaired or requires a disability ID. People with a medical disability receive a disability identification card.
The form has three parts:
- Patient Information, where the driver identifies themselves and authorizes their physician to release the listed medical information to DPS.
- Three certification sections completed by the physician: Certification of Diabetes, Certification of Hearing-Impaired Driver and Persons with Disabilities ID Card.
- Physician Information, where the physician certifies that the patient is currently under their care and diagnosed with the condition indicated, and that the physician is licensed.
The hearing section prints the standard used to decide whether a Hearing-impaired Driver indicator can be placed on a license. The disability section lists mobility conditions and whether the disability is permanent or temporary.
Who needs to file Physician Certification Form – Mississippi?
Drivers and ID card applicants in Mississippi who want a medical symbol or a disability ID need a physician to complete this form. The Driver Service Bureau uses it in three situations:
- A driver or ID holder with diabetes who wants a diabetes symbol; the physician also marks whether the patient is injection (shot) dependent, diet controlled or oral (pill) dependent.
- A driver who is hearing impaired and wants the Hearing-impaired Driver indicator on a driver license.
- A person who applies for a disability identification card; the Bureau's page lists the completed form among the items every applicant for that card must provide.
Someone who already holds an ID card and wants a medical symbol for the hearing impaired or for a medical disability must also provide this form, and a duplicate fee applies.
The patient signs the authorization for release of medical information. The physician completes the certification sections and must be a licensed physician who has the patient under their care. A physician cannot certify a patient who is not under their care, according to the form's own wording.
When to file Physician Certification Form – Mississippi
Have the form completed before you go to a Driver Service Bureau station. The Bureau's page says the Physician Certification Form must be filled out by the physician prior to obtaining the disability ID, and that all applicable forms must be completed before you return to any Driver Service Bureau station. If you already have an ID card and want a medical symbol for hearing impairment or a medical disability, bring the form when you request it. The form itself prints no expiration date or deadline; for a temporary disability the physician writes the approximate length of time the disability will last.
How to fill out Physician Certification Form – Mississippi
Enter the driver's information
Under Patient Information, type or print the Driver Name, Date of Birth (MM / DD / YYYY boxes), Driver Address and Driver License/ID Number.
Authorize release of medical information
Write the patient's name on the line after "I," to authorize the physician to release the listed medical information to the Mississippi Department of Public Safety. The patient then signs and dates the Patient's Signature line.
Complete the diabetes certification
The physician checks the box certifying a diabetes diagnosis, if it applies, and checks all that apply: Injection (shot) Dependent, Diet Controlled or Oral (pill) Dependent.
Complete the hearing-impaired certification
If it applies, the physician checks the box certifying a hearing impairment and the hearing standard printed on the form. The physician then checks Hearing aid used for tests and/or Hearing aid required to meet standard.
Complete the disability ID section
For the Persons with Disabilities ID Card, the physician checks the certification box and all the conditions that apply, such as being unable to walk 200 feet without stopping to rest or needing an assistive device.
Mark permanent or temporary disability
The physician checks either the permanent disability box or the temporary disability box. For a temporary disability, write the approximate period it will last on the line provided.
Enter the physician's details
In Physician Information, the physician prints their name and enters the Medical License No. This section certifies that the patient is currently under the physician's care with the diagnosis indicated and that the physician is licensed.
Sign, date and download the PDF
The physician signs and dates the form; the signature must be in blue ink. Review every section, then download or print the completed PDF from FillingPDF and bring it to a Driver Service Bureau station as described under How to submit.
How to submit Physician Certification Form – Mississippi
You bring the completed form to a Driver Service Bureau station; the form prints no mailing address for it.
- In person: Take the completed, signed form to any Driver Service Bureau station with the rest of your application. If you already have an ID card and want a medical symbol for hearing impairment or a medical disability, provide the form and pay the duplicate fee at any Driver Service location; the Bureau's page lists the current fee.
- Appointment: The Driver Service Bureau highly recommends that applicants make an appointment at dps.ms.gov/appointment.
- Questions: The form lists DPS at P.O. Box 958, Jackson, MS 39205-0958, phone (601) 987-1224, www.dps.ms.gov.
Before you go, check that the patient has signed the authorization and that the physician has completed and signed the form in blue ink. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Having the physician sign in black ink; the form states the physician's signature must be in blue ink.
- Leaving the patient's authorization unsigned, so the physician is not authorized to release the medical information to DPS.
- Checking a certification box without marking the "check all that apply" options, such as the diabetes treatment type or the hearing aid boxes.
- Marking the temporary disability box without writing the approximate period the disability will last.
- Omitting the physician's printed name or Medical License No. in the Physician Information section.
- Going to a Driver Service Bureau station before the physician has completed the form; the Bureau says all applicable forms must be completed first.
- Asking for a medical symbol on an existing ID card without bringing the form and paying the duplicate fee.
- Completing sections for conditions the patient does not have instead of only the ones the physician certifies.
Frequently asked questions
What is the Physician Certification Form used for in Mississippi?
It lets a licensed physician certify diabetes, hearing impairment or a disability so the Driver Service Bureau can place a symbol on a driver license or ID card, or issue a disability identification card. The patient also authorizes release of the medical information to DPS.
Who has to complete the Physician Certification Form?
The physician completes the certification and physician sections, and the patient fills in the driver information and signs the authorization. The physician certifies that the patient is currently under their care and that the physician is licensed.
Does the physician have to sign in blue ink?
Yes. The form prints "Signature Must be in BLUE Ink" under the Physician's Signature line. The patient's signature on the authorization line has no such instruction on the form.
Do I need this form to get a disability ID card in Mississippi?
Yes. The Driver Service Bureau lists the Physician Certification Form, filled out by the physician before you obtain the ID, among the items every disability identification card applicant must provide, along with the application and other documents.
Can I add a hearing-impaired or medical symbol to my existing ID card?
Yes. If you already have an ID card, provide the Physician Certification Form and pay the duplicate fee at any Driver Service location. The Bureau's page gives the current fee, so check it before you go.
Where do I turn in the Physician Certification Form?
Take the completed form to a Driver Service Bureau station with the rest of your application; the form prints no mailing address for it. The Bureau highly recommends making an appointment at dps.ms.gov/appointment.
Can I fill out the Physician Certification Form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is not affiliated with DPS and does not file the form; the physician must still sign it in blue ink and you bring it to a Driver Service Bureau station.
What hearing standard does the form use?
The form says a driver must first perceive forced whispered voice > 5 ft., with or without hearing aid, or have an average hearing loss in the better ear < 40 dB, to be issued a Hearing-impaired Driver indicator on the license.
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