Tennessee exempts an operator or passenger from safety belt and safety seat restraint when a physician certifies, under T.C.A. § 55-9-603(h), a diagnosed physical disability that prevents appropriate restraint. A clinician meets it when a patient asks for a medical seat belt waiver. On this one-page certificate the physician describes the disability and why a restraint is inappropriate, and the patient keeps the signed form in the vehicle.
The physician prints their name as the certifying physician, writes the nature of the disability and the reason a restraint is inappropriate, then signs and dates. The top of the form names the operator or passenger covered and their driver license number.
Download the current version from the source each time; forms change without notice.
Tennessee Safety Belt Physical Disability Exemption
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. The form states it should be kept in the vehicle with the operator or passenger it covers. It is a physician's certification under T.C.A. § 55-9-603(h), so the signed original stays with the patient rather than going to the Department of Safety and Homeland Security.
A physician. The form says the condition is certified in accordance with T.C.A. § 55-9-603(h) by a physician, whose printed name, signature and date appear on it. It has no lines for a nurse practitioner, physician assistant or other practitioner.
The form does not state a validity period: it has no expiration or renewal field, and the only date on it is the one next to the physician's signature. It certifies a diagnosed physical disability, and the signed copy stays in the vehicle with the person it covers.