SGI's Medical Review Unit uses this one-page form to receive written concerns about a person's medical fitness to drive. The reporter identifies the driver and describes in detail, with specific examples, incidents or symptoms, why the unit should investigate further. Although titled for private citizens, it is also accepted from medical practitioners and medical offices.
The person raising the concern completes the whole form and signs it; for a clinician or clinic, that means entering the driver's details and the detailed reasons, then signing and dating as the sender.
Download the current version from the source each time; forms change without notice.
Confidential Reporting Form - Private Citizen
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 change without notice, so download the current version from the official page before you fill it in.
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Not automatically. The form's header states that forms completed or submitted by medical practitioners or medical offices will not be kept confidential unless the sender requests it. A clinician who wants confidentiality needs to ask for it when sending the form to the Medical Review Unit.
The form asks for the driver's name, address, date of birth or age and SGI customer number if known, then a detailed description of why the unit should investigate the person's medical fitness to drive, including specific examples, incidents and symptoms. The sender signs and dates it.
Yes. The form is titled for private citizens, but its header addresses forms completed or submitted by medical practitioners and medical offices, so SGI accepts it from them. The difference is confidentiality, which applies to a clinician's form only when the sender requests it.