DMV medical forms and vision reports for clinicians, by state

The vision reports, medical evaluations and impaired-driver reports that state licensing agencies ask clinicians to complete, grouped by state.

State licensing agencies ask clinicians for two kinds of forms. Vision reports from an optometrist or ophthalmologist, such as California's Report of Vision Examination (DL 62), Michigan's DA-4V and South Carolina's 412-NC, cover acuity and fields. Medical reports, such as Michigan's Physician's Statement of Examination (DA-4P), California's Driver Medical Evaluation (DS 326) and New York's MV-80U.1, support a medical review. The District of Columbia also requires a Mature Driver Fitness to Drive Certification from every driver 70 or older at renewal.

Reporting rules differ by state. Pennsylvania's DL-13 and Oregon's Mandatory Impairment Referral (735-7230) are mandatory reports, while New York's DS-6 is voluntary. Watch the dates: many forms are valid only for a set time after the exam or your signature. Some go back to the agency from your office, others with the patient. Puerto Rico's forms are in Spanish only, and 8 forms here have a Spanish version. Vero Documents fills these PDFs from the visit note and the chart.

Federal

Certifies that a person who drives vehicles carrying migrant agricultural workers meets the physical qualifications of 49 CFR 398.3(b) under the Migrant and Seasonal Agricultural Worker Protection Act (MSPA).

Completed by
Licensed doctor of medicine or osteopathy
Issued by
U.S. Department of Labor, Wage and Hour Division
Format
Fillable PDF
Language
English

Alaska

Collects eye, medical, loss-of-consciousness/seizure and mental health assessments so DMV can decide whether the patient can safely operate a motor vehicle.

Completed by
Optometrist/ophthalmologist (eye section), physician or neurologist (medical and seizure sections), physician, psychiatrist or psychologist (mental section)
Issued by
State of Alaska Division of Motor Vehicles, Driver Services
Format
Fillable PDF
Language
English

California

Reports an eye examination (refraction, visual acuity, fields, conditions) for an applicant who did not meet DMV's visual acuity screening standard.

Completed by
Ophthalmologist or optometrist
Issued by
California Department of Motor Vehicles
Format
Fillable PDF
Language
English

Gives DMV Driver Safety a medical professional's evaluation of a condition that may affect the patient's ability to drive safely, for a licensing decision or medical reexamination.

Completed by
Medical professional most familiar with the driver's health (physician, PA, NP)
Issued by
California Department of Motor Vehicles, Driver Safety
Format
Fillable PDF
Language
English

Mandatory physician report (H&S Code 103900) of a patient aged 14+ diagnosed with a disorder characterized by lapses of consciousness, Alzheimer's/related disorders or similar conditions; the local health officer forwards it to DMV for licensing action.

Completed by
Physician (or surgeon) who diagnosed the condition
Issued by
California Department of Public Health (submitted to the local health officer, who reports to DMV)
Format
Fillable PDF
Language
English

Solicitud Para Reexaminación de Conductor

Asks DMV to reevaluate a driver's ability to drive safely because of a physical, mental or vision condition or observed unsafe driving.

Completed by
Any reporter; commonly the driver's physician or other health professional, family member or law enforcement
Issued by
California Department of Motor Vehicles, Driver Safety
Format
Fillable PDF
Language
English and Spanish

Reporte Médico Sobre La Salud

Physician's certification that the applicant has no impairment precluding driving a house car over 40 feet or being a driving school instructor (non-commercial health requirement).

Completed by
Physician
Issued by
California Department of Motor Vehicles
Format
Fillable PDF
Language
English and Spanish

Colorado

Physician's or APRN's assessment of conditions and degree of impairment relative to the driving task, used by the DMV to decide licensing, restrictions or re-evaluation.

Completed by
Physician or advanced practice registered nurse (PA referenced in the immunity clause)
Issued by
Colorado Department of Revenue, Division of Motor Vehicles
Format
Fillable PDF
Language
English

Eye examination report on visual fitness to operate a motor vehicle, for licensing or medical re-evaluation.

Completed by
Physician, ophthalmologist or optometrist
Issued by
Colorado Department of Revenue, Division of Motor Vehicles
Format
Fillable PDF
Language
English

Connecticut

Medical examiner's report on a patient referred to DMV about their ability to safely operate a motor vehicle, reviewed by DMV and its Medical Advisory Board.

Completed by
Licensed physician, PA or APRN
Issued by
Connecticut Department of Motor Vehicles, Driver Services Division
Format
Fillable PDF
Language
English

Eye care professional's report on vision of a patient referred to DMV about their ability to drive safely.

Completed by
Licensed physician, optometrist or ophthalmologist
Issued by
Connecticut Department of Motor Vehicles, Driver Services Division
Format
Fillable PDF
Language
English

Lets a hospital emergency room physician report a person diagnosed with a health problem that will significantly affect their ability to drive safely (CGS 14-46).

Completed by
Emergency department physician
Issued by
Connecticut Department of Motor Vehicles, Driver Services Division
Format
Fillable PDF
Language
English

Orthopedic evaluation supporting an intrastate commercial driver's Skill Performance Evaluation (limb impairment) waiver.

Completed by
Board-certified or board-qualified orthopedic surgeon or physiatrist
Issued by
Connecticut Department of Motor Vehicles, Driver Services Division
Format
PDF
Language
English

Medical report supporting an intrastate commercial driver's application for a seizure medical waiver, reviewed by the DMV Medical Advisory Board.

Completed by
Medical examiner (licensed physician, PA or APRN)
Issued by
Connecticut Department of Motor Vehicles, Driver Services Division
Format
PDF
Language
English

Delaware

Licensed practitioner's findings on neuropsychological, neurological, orthopedic, cardiopulmonary, diabetic, vision/hearing, substance-use and medication issues, with a recommendation on whether the customer should be allowed to drive.

Completed by
Customer's licensed practitioner (physician, NP, PA)
Issued by
Delaware Division of Motor Vehicles, Medical Section
Format
Fillable PDF
Language
English

District of Columbia

Informe Médico/de Visión

Licensed medical practitioner's and/or eye doctor's report on a condition (seizures, dementia, insulin-treated diabetes, vision impairment, etc.) that may impair safe driving, used to issue, restrict or limit a license.

Completed by
Licensed medical practitioner (medical report); ophthalmologist or optometrist (eye report)
Issued by
District of Columbia Department of Motor Vehicles
Format
PDF
Language
English and Spanish

Georgia

DDS-MR 287

Medical Report

Physician's evaluation of the medical concerns listed in a DDS medical review letter, used to clear, restrict or revoke the driver's license.

Completed by
Licensed physician (FMCSA National Registry medical examiner for commercial license holders)
Issued by
Georgia Department of Driver Services, Medical Review Unit
Format
PDF
Language
English

Eye doctor's report of visual acuity and recommended restrictions (no expressways, daylight only, bioptic) when vision is in question during a medical review or licensing.

Completed by
Optometrist or ophthalmologist
Issued by
Georgia Department of Driver Services, Medical Review Unit
Format
PDF
Language
English

Healthcare provider specifies the adaptive equipment or restrictions (hand controls, left accelerator, mirrors, automatic transmission, etc.) a driver needs to drive safely.

Completed by
Healthcare provider (e.g. physician, occupational therapist / driver rehab specialist)
Issued by
Georgia Department of Driver Services, Medical Review Unit
Format
Fillable PDF
Language
English

Hawaii

Medical examination report giving the county examiner of drivers information on whether the applicant meets Hawaii's physical and mental licensing standards; may be referred to the Medical Advisory Board (NHTSA Driver Fitness Medical Guidelines).

Completed by
Licensed medical doctor (or other competent authority acceptable to the examiner of drivers)
Issued by
Hawaii Department of Transportation, Motor Vehicle Safety Office (used by county examiners of drivers)
Format
Fillable PDF
Language
English

Illinois

Eye specialist's report of acuity (incl. telescopic/bioptic readings) and visual fields for an applicant who failed the Secretary of State vision screening.

Completed by
Ophthalmologist (MD/DO) or optometrist (OD)
Issued by
Illinois Secretary of State, Driver Services Department
Format
Fillable PDF
Language
English

Indiana

Iowa

Vision specialist's report of visual acuity and conditions when a driver fails vision screening or a vision report is required at renewal.

Completed by
Vision specialist (optometrist or ophthalmologist)
Issued by
Iowa Department of Transportation, Driver & Identification Services
Format
Online only
Language
English

Kansas

Medical and/or psychological professional's report on whether the patient can safely operate a motor vehicle, recommended restrictions, and Medical Advisory Board review.

Completed by
Medical and/or psychological professional (physician, APRN, PA, psychologist)
Issued by
Kansas Department of Revenue, Division of Vehicles, Medical/Vision Unit
Format
Fillable PDF
Language
English

Vision professional's report of acuity, fields and recommended restrictions (or Medical Advisory Board review) for a driver referred to the Medical/Vision Unit.

Completed by
Optometrist or ophthalmologist
Issued by
Kansas Department of Revenue, Division of Vehicles, Medical/Vision Unit
Format
Fillable PDF
Language
English

Kentucky

Reports a vision examination done for driver vision testing before an initial permit, initial license, renewal or reinstatement (KRS 186.577), including failures referred to the Medical Review Board.

Completed by
Vision specialist (optometrist/ophthalmologist) or KYTC-credentialed medical specialist (physician, osteopath, APRN)
Issued by
Kentucky Transportation Cabinet, Division of Driver Licensing
Format
PDF
Language
English

Condition-specific medical reports supporting an intrastate CDL medical waiver for applicants who do not meet federal DOT physical standards.

Completed by
Treating physician or specialist for the condition (eye doctor for vision)
Issued by
Kentucky Transportation Cabinet, Division of Driver Licensing, CDL Section
Format
Sent for each case
Language
English

Reports a driver with a physical or mental impairment to the Medical Review Board, which then opens a case and sends medical forms to the driver.

Completed by
Reporter: physician, law enforcement, other officials, or citizens (citizens need notarized signatures)
Issued by
Kentucky Transportation Cabinet, Department of Vehicle Regulation, Medical Review Board Office
Format
PDF
Language
English

Louisiana

Optometrist's or ophthalmologist's report of visual acuity (each eye and both) and opinion on driving from a vision standpoint.

Completed by
Optometrist or ophthalmologist
Issued by
Louisiana Department of Public Safety and Corrections, Office of Motor Vehicles
Format
Fillable PDF
Language
English

Physician's report (history, neurological, cardiopulmonary, mental, diabetes, hearing, etc.) on an applicant's ability to safely operate a motor vehicle when OMV suspects a physical or mental infirmity.

Completed by
Physician
Issued by
Louisiana Department of Public Safety and Corrections, Office of Motor Vehicles
Format
Fillable PDF
Language
English

Reports a suspected unsafe driver based on firsthand knowledge of driving behavior or a medical/physical condition.

Completed by
Courts, law enforcement, health care providers, OMV staff or family members
Issued by
Louisiana Department of Public Safety and Corrections, Office of Motor Vehicles
Format
PDF
Language
English

Maine

Advisory report by a medical or paramedical professional on a physical, emotional or mental condition that could affect safe driving, applied under Maine's Functional Ability Profile rules to determine license eligibility.

Completed by
Appropriate medical or paramedical professional (physician, NP, PA, etc.)
Issued by
Maine Secretary of State, Bureau of Motor Vehicles, Medical Section
Format
Fillable PDF
Language
English

Licensed vision examiner's report of acuity, continuous visual field and conditions under the Functional Ability Profile rules, including bioptic use and exceptional-case review requests.

Completed by
Licensed vision examiner (optometrist or ophthalmologist)
Issued by
Maine Secretary of State, Bureau of Motor Vehicles, Medical Section
Format
Fillable PDF
Language
English

Supplements the Driver Medical Evaluation with narcolepsy/cataplexy treatment, adherence, Epworth Sleepiness Scale score and cataplexy episode details.

Completed by
Treating clinician (sleep medicine/neurology/primary care)
Issued by
Maine Secretary of State, Bureau of Motor Vehicles, Medical Section
Format
Word document
Language
English

Massachusetts

Eye doctor's certification that a Class D/M applicant meets RMV minimum visual standards, used in place of the RMV vision test.

Completed by
Ophthalmologist or Massachusetts-licensed optometrist
Issued by
Massachusetts Registry of Motor Vehicles
Format
Fillable PDF
Language
English

Physician's evaluation of a driver's medical fitness to drive when the RMV has requested a medical evaluation, certified under penalty of perjury.

Completed by
Medical doctor licensed in Massachusetts
Issued by
Massachusetts Registry of Motor Vehicles, Medical Affairs
Format
Fillable PDF
Language
English

Lets a medical provider or law enforcement official report a person believed no longer physically and/or cognitively capable of driving safely.

Completed by
Medical provider (or law enforcement official)
Issued by
Massachusetts Registry of Motor Vehicles, Medical Affairs
Format
Fillable PDF
Language
English

Physician's evaluation of a seizure or other loss/alteration of consciousness episode, including any request to waive the standard six-month no-driving period.

Completed by
Medical doctor licensed in Massachusetts
Issued by
Massachusetts Registry of Motor Vehicles, Medical Affairs
Format
Fillable PDF
Language
English

Eye doctor's certification that a Class A/B/C permit or license applicant meets FMCSA vision standards.

Completed by
Ophthalmologist or Massachusetts-licensed optometrist
Issued by
Massachusetts Registry of Motor Vehicles
Format
Fillable PDF
Language
English

Psychiatric evaluation of whether a mental health condition impairs a driver's ability to operate a motor vehicle safely.

Completed by
Massachusetts-licensed medical doctor or psychiatric nurse practitioner
Issued by
Massachusetts Registry of Motor Vehicles, Medical Affairs
Format
Fillable PDF
Language
English

Michigan

Physician's diagnosis, prognosis, cognitive screening (MoCA, clock drawing, Trails A&B), loss-of-consciousness history and recommended restrictions for a driver referred for a driver assessment reexamination; also used to request a tinted-window restriction.

Completed by
Physician, PA, psychologist or NP (an NP needs the supervising physician's countersignature)
Issued by
Michigan Department of State, Driver Assessment Section
Format
Fillable PDF
Language
English

Vision specialist's report of acuity, peripheral fields, ocular diagnoses and recommended restrictions (incl. bioptic telescope section) for licensing or driver assessment.

Completed by
Vision specialist (ophthalmologist or optometrist)
Issued by
Michigan Department of State, Driver Assessment Section
Format
Fillable PDF
Language
English

Requests that the Department of State evaluate a person's ability to drive safely under MCL 257.320.

Completed by
Any requestor (physician, law enforcement, family, agency)
Issued by
Michigan Department of State, Driver Assessment Section
Format
Fillable PDF
Language
English

Minnesota

Licensed vision examiner's report of visual acuity and recommended restrictions for a driver who did not pass DVS vision screening.

Completed by
Licensed vision examiner (optometrist or ophthalmologist)
Issued by
Minnesota Department of Public Safety, Driver and Vehicle Services
Format
Fillable PDF
Language
English

Physician's report used to determine a driver's eligibility after loss of consciousness or voluntary control (seizures, syncope, diabetic episodes), including the review interval.

Completed by
Physician
Issued by
Minnesota Department of Public Safety, Driver and Vehicle Services, Driver Evaluation Unit
Format
Fillable PDF
Language
English

Ophthalmologist's report on whether diabetes has affected the eye health (e.g. unstable proliferative retinopathy) of an applicant for an intrastate school bus driver medical waiver.

Completed by
Ophthalmologist
Issued by
Minnesota Department of Public Safety, Driver and Vehicle Services
Format
PDF
Language
English

Supports a restricted license for a 15-year-old to drive for personal medical reasons or to drive a relative for medical reasons or due to a disability (Minn. Stat. 171.042).

Completed by
Relative or doctor (doctor may instead provide a letterhead statement)
Issued by
Minnesota Department of Public Safety, Driver and Vehicle Services
Format
Fillable PDF
Language
English

Requests DVS reexamination of a driver for physical, mental, diabetic or seizure-related loss of control, vision or knowledge/skill problems.

Completed by
Any reporter (physician, law enforcement, family, public)
Issued by
Minnesota Department of Public Safety, Driver and Vehicle Services, Driver Evaluation Unit
Format
Fillable PDF
Language
English

Mississippi

Ophthalmologist's or optometrist's report of acuity with and without lenses and field of vision for a driver under medical/vision review.

Completed by
Ophthalmologist or optometrist
Issued by
Mississippi Department of Public Safety, Driver Service Bureau
Format
Fillable PDF
Language
English

Physician's medical report used by DPS to decide on licensing after a safety concern letter or examiner referral (seizures, physical impairment, etc.), before a driving evaluation.

Completed by
Licensed physician / licensed medical professional
Issued by
Mississippi Department of Public Safety, Driver Service Bureau, Driver Records Medical Division
Format
Fillable PDF
Language
English

Missouri

Eye examination results and opinion on whether the patient's visual abilities are adequate to drive safely.

Completed by
Physician (ophthalmologist) or optometrist
Issued by
Missouri Department of Revenue, Driver License Bureau
Format
Fillable PDF
Language
English

Medical provider's examination findings and opinion on the patient's fitness to operate a motor vehicle, requested by the Driver License Bureau during a driver medical review.

Completed by
Physician or other eligible medical provider
Issued by
Missouri Department of Revenue, Driver License Bureau
Format
Fillable PDF
Language
English

Reports firsthand knowledge of a driver believed no longer able to drive safely (cognitive, visual, consciousness, mobility, substance issues), which may trigger medical, vision or driving tests.

Completed by
Physician, chiropractor, registered nurse, psychologist, optometrist, PT/OT, social worker, professional counselor, EMT, law enforcement or immediate family
Issued by
Missouri Department of Revenue, Driver License Bureau
Format
Fillable PDF
Language
English

Montana

Physician/provider evaluation of a condition MVD records indicate may affect safe driving, used for a licensing decision.

Completed by
Physician or other treating provider
Issued by
Montana Department of Justice, Motor Vehicle Division
Format
Fillable PDF
Language
English

Eye specialist's report verifying that a driver meets Montana vision standards for license issuance.

Completed by
Eye specialist (optometrist or ophthalmologist)
Issued by
Montana Department of Justice, Motor Vehicle Division
Format
PDF
Language
English

Nebraska

Eye doctor reports acuity, visual field and lens type when a driver fails the DMV vision screening or is under vision review.

Completed by
Optometrist or ophthalmologist
Issued by
Nebraska Department of Motor Vehicles
Format
PDF
Language
English

Physician reports neurological, cardiovascular, diabetic, alcohol/drug and other conditions so the DMV can decide whether a driver or applicant may be licensed.

Completed by
Examining physician
Issued by
Nebraska Department of Motor Vehicles
Format
PDF
Language
English

Nevada

Clinician reports diagnosis, stability, medications, seizure/loss-of-consciousness history and recommended restrictions so the DMV can assess a motorist's ability to drive.

Completed by
Physician, APRN or physician assistant
Issued by
Nevada Department of Motor Vehicles
Format
Fillable PDF
Language
English

Records acuity with and without correction and any progressive eye disease for an applicant who failed the DMV vision screening.

Completed by
Physician or optometrist licensed in Nevada
Issued by
Nevada Department of Motor Vehicles
Format
Fillable PDF
Language
English

Physician certifies a medical need for darker window tint, the recommended visible light transmittance and whether the permit should be 4-year or indefinite.

Completed by
Physician currently licensed in Nevada
Issued by
Nevada Department of Public Safety, Highway Patrol Division
Format
Fillable PDF
Language
English

New Hampshire

Eye doctor records acuity without lenses, with old and with new lenses and recommends whether the applicant is visually capable of a NH license (min. 20/40 both eyes or 20/30 one eye); Part C covers the special 20/40-20/70 visual acuity requirements under Saf-C 1004.08.

Completed by
Ophthalmologist or optometrist (Part A/B); medical doctor (Part C, Sections I/II certification)
Issued by
New Hampshire Department of Safety, Division of Motor Vehicles
Format
Fillable PDF
Language
English

Physical examination (vision, hearing, reflexes, 5-year illness history) and Licensed Physician's Certificate for a NH school bus certificate applicant.

Completed by
Licensed physician
Issued by
New Hampshire Department of Safety, Division of Motor Vehicles
Format
Fillable PDF
Language
English

Intrastate commercial driver who does not meet 49 CFR 391.41 applies for a NH waiver (up to 2 years); includes a Medical Evaluation Summary by a licensed physician per Saf-C 909.07.

Completed by
Licensed physician (Medical Evaluation Summary)
Issued by
New Hampshire Department of Safety, Division of Motor Vehicles
Format
PDF
Language
English

Licensed physician certifies a diagnosis of autism spectrum disorder, deafness/hard of hearing or another disorder authorized in RSA 263:41-b so it is indicated on the NH license or non-driver ID.

Completed by
Licensed physician
Issued by
New Hampshire Department of Safety, Division of Motor Vehicles
Format
Fillable PDF
Language
English

New Jersey

Physician or emergency room reports a driver's seizure or loss-of-consciousness episode (history, EEG, classification) to the MVC for medical review.

Completed by
Physician or emergency room clinician
Issued by
New Jersey Motor Vehicle Commission, Medical Fitness Review Unit
Format
Fillable PDF
Language
English

New Mexico

MVD-10125

Vision Report

Eye doctor reports acuity, fields (120 degrees horizontal), progressive conditions, restrictions and renewal interval for a driver who failed the MVD vision test.

Completed by
Ophthalmologist or optometrist
Issued by
New Mexico Taxation & Revenue Department, Motor Vehicle Division
Format
PDF
Language
English

Physician reports conditions (neurological, cardiovascular, diabetes, dementia, epilepsy, loss of consciousness, etc.), capability to drive, restrictions and renewal interval for a Class D/E/M license, permit or provisional license; reviewed by the Medical Advisory Board.

Completed by
Physician or other licensed health care provider
Issued by
New Mexico Taxation & Revenue Department, Motor Vehicle Division
Format
PDF
Language
English

New York

Driver's clinician reports medical, physical or mental conditions (epilepsy, syncope, diabetes, sleep disorder, dementia, heart condition, stroke, etc.) and whether they interfere with safe driving, for DMV Medical Review.

Completed by
Physician, physician assistant or nurse practitioner (emergency care personnel not accepted)
Issued by
New York State Department of Motor Vehicles
Format
Fillable PDF
Language
English

Provider records a vision test for license renewal by mail/online when the provider is not enrolled in DMV's Vision Registry.

Completed by
Licensed physician, PA, RN, NP, optician, optometrist, ophthalmologist, or their supervised staff
Issued by
New York State Department of Motor Vehicles
Format
Fillable PDF
Language
English

Physician, PA or NP reports a person whose driving ability may be affected by a physical or mental impairment, with an opinion on whether privileges should be suspended.

Completed by
Licensed physician, physician assistant or nurse practitioner
Issued by
New York State Department of Motor Vehicles
Format
Fillable PDF
Language
English

Short statement from the driver's clinician confirming examination, medications, any loss of consciousness or body control, and an opinion on driving ability.

Completed by
Physician, physician assistant or nurse practitioner
Issued by
New York State Department of Motor Vehicles
Format
Fillable PDF
Language
English

Eye examiner reports acuity and fields for the Low Vision Program (corrected vision 20/40-20/70) or telescopic lens wearers, including bioptic training certification.

Completed by
Physician, ophthalmologist or optometrist
Issued by
New York State Department of Motor Vehicles
Format
Fillable PDF
Language
English

North Carolina

Multi-section report (general, vision, cardiovascular, endocrine/diabetes, neurological, psychiatric, substance use, etc.) the Medical Review Unit sends to a driver so their physician can document fitness to drive and recommend restrictions.

Completed by
Treating physician; vision section by a licensed ophthalmologist or optometrist
Issued by
North Carolina Division of Motor Vehicles, Medical Review Unit
Format
Fillable PDF
Language
English

Oklahoma

Provider certifies an autism spectrum disorder diagnosis so the individual can add a voluntary autism designation to their Oklahoma driver license or ID (47 O.S. 6-125).

Completed by
Licensed primary care physician, licensed psychologist or licensed psychiatrist
Issued by
Service Oklahoma
Format
Fillable PDF
Language
English

Provider certifies an epilepsy diagnosis so the individual can add a voluntary epilepsy designation to their Oklahoma driver license or ID (47 O.S. 6-130).

Completed by
Licensed primary care physician, licensed psychologist or licensed psychiatrist
Issued by
Service Oklahoma
Format
Fillable PDF
Language
English

Oregon

Vision specialist reports acuity and field results for an applicant who did not pass the DMV vision screening (ORS 807.090).

Completed by
Licensed vision specialist (optometrist or ophthalmologist)
Issued by
Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)
Format
Fillable PDF
Language
English

Mandatory report by a physician or health care provider of a patient with a severe and uncontrollable cognitive or functional impairment (OAR 735-074) that may make driving unsafe, triggering DMV suspension or evaluation.

Completed by
Mandatory reporters: primary care provider (incl. hospitalists), specialist physician/PA/NP on referral, or health care provider on referral (chiropractor, NP, OT, PT, optometrist, PA, podiatrist, mental health provider)
Issued by
Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)
Format
Fillable PDF
Language
English

Health care provider who treats the driver's condition states why the driver cannot operate an ignition interlock device and whether the condition is permanent or temporary, supporting an exemption from a court or DMV IID requirement.

Completed by
Health care provider providing specialized treatment for the condition
Issued by
Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)
Format
Fillable PDF
Language
English

Pennsylvania

Generic mandatory report of a patient's disorder or disability that may impair driving (75 Pa.C.S. 1518), used when the provider lacks history or condition-specific knowledge; PennDOT then requests details.

Completed by
Physicians and other persons authorized to diagnose/treat (mandatory reporters), including emergency room personnel
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Records corrected/uncorrected acuity and visual field against PA minimum vision standards (67 Pa. Code 83.3; 71.3 for school bus drivers) for licensing or medical review.

Completed by
Optometrist, ophthalmologist, physician assistant, certified registered nurse practitioner, or licensed physician with equipment to evaluate vision
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting cardiovascular or cerebrovascular disease (syncope, loss of consciousness, vertigo, dyspnea) under 67 Pa. Code 83.5, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting seizure disorder/epilepsy, including seizure-free interval and waiver requests (67 Pa. Code 83.4), so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting diabetes mellitus, including hypoglycemic episodes, that may affect safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting other medical conditions that affect safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting neurological conditions affecting control of a vehicle, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting loss of consciousness or awareness, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting cognitive impairment such as dementia that may affect safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting psychiatric disorders affecting attention, judgment or behavior while driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting orthopedic impairment or loss of a limb affecting vehicle control, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting substance use affecting safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).

Completed by
Treating physician or other health care provider
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting hearing for school bus drivers (67 Pa. Code 71.3), so the Bureau can decide whether the driver meets school bus driver standards.

Completed by
Treating physician or other health care provider examining a school bus driver
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Condition-specific medical report to PennDOT documenting substance abuse history for school bus drivers, so the Bureau can decide whether the driver meets school bus driver standards.

Completed by
Treating physician or other health care provider examining a school bus driver
Issued by
Pennsylvania Department of Transportation (PennDOT), Bureau of Driver Licensing
Format
Fillable PDF
Language
English

Puerto Rico

Medical Certification for Driver's License Certificate

Physician personally examines a learner's permit or driver's license applicant (visual acuity, physical and mental condition) and certifies whether they are fit to drive under Ley 22-2000.

Completed by
Physician licensed to practice in Puerto Rico
Issued by
Departamento de Transportación y Obras Públicas (DTOP), Directoria de Servicios al Conductor (CESCO), Puerto Rico
Format
PDF
Language
Spanish

Ophthalmologist or Optometrist Certificate

Eye doctor reports acuity, depth perception, peripheral vision and whether the applicant can drive (with lenses or daylight-only), required for heavy and Tipo 1-4 categories.

Completed by
Ophthalmologist or optometrist authorized to practice in Puerto Rico
Issued by
Departamento de Transportación y Obras Públicas (DTOP), Directoria de Servicios al Conductor (CESCO), Puerto Rico
Format
PDF
Language
Spanish

Medical Certification for Commercial Passenger Motor Vehicle Driver's License

Physician examines an applicant for chofer/heavy passenger categories, covering amputations, insulin-treated diabetes, cardiovascular, respiratory, hypertension, musculoskeletal and other conditions.

Completed by
Physician licensed in Puerto Rico
Issued by
Departamento de Transportación y Obras Públicas (DTOP), Directoria de Servicios al Conductor (CESCO), Puerto Rico
Format
PDF
Language
Spanish

Medical Certification for Seat Belt or Window Tint Exemption

Specialist physician certifies the patient's diagnosis and why a seat belt cannot be used or darker window tint is medically needed.

Completed by
Specialist physician authorized to practice medicine in Puerto Rico
Issued by
Departamento de Transportación y Obras Públicas (DTOP), Directoria de Servicios al Conductor (CESCO), Puerto Rico
Format
PDF
Language
Spanish

South Carolina

Physician certifies up to three medical conditions (and a medical provider certifies blood type) so a caduceus symbol can be printed on a non-commercial SC permit, license or ID (SC Code 56-1-80).

Completed by
SC-licensed physician (conditions); medical provider (blood type)
Issued by
South Carolina Department of Motor Vehicles
Format
Fillable PDF
Language
English

Tennessee

Texas

Physician or psychiatrist certifies a health condition that may impede communication with a peace officer so 'Communication Impediment' or 'Deaf or Hard of Hearing' is printed on the Texas DL/ID (Transportation Code 521.142(h)).

Completed by
Licensed physician or licensed psychiatrist
Issued by
Texas Department of Public Safety, Driver License Division
Format
Fillable PDF
Language
English

Utah

Vision health care professional reports acuity and visual fields (90/60 degree thresholds), stability and recommended review time or restrictions.

Completed by
Vision health care professional
Issued by
Utah Department of Public Safety, Driver License Division
Format
PDF
Language
English

Health care professional rates the driver in each medical category (diabetes, cardiovascular, pulmonary, neurologic, seizures, learning/memory, mental health, alcohol/drugs, musculoskeletal, sleep, etc.) on Utah's A-K / 1-8 functional ability levels and recommends review time and restrictions.

Completed by
Health care professional (HCP)
Issued by
Utah Department of Public Safety, Driver License Division
Format
PDF
Language
English

Health care professional certifies a listed invisible condition (autism, epilepsy, diabetes, dementia, deafness, etc.) so DLD adds an identification symbol to the license/ID record shared with law enforcement (UCA 53-3-207).

Completed by
Health care professional as defined in UCA 53-3-207
Issued by
Utah Department of Public Safety, Driver License Division
Format
PDF
Language
English

Health care professional documents diagnoses, treatment and test results showing a driver cannot provide a deep-lung breath sample, supporting a petition to remove an ignition interlock requirement.

Completed by
Health care professional
Issued by
Utah Department of Public Safety, Driver License Division
Format
PDF
Language
English

Vermont

One medical form used for license/permit applications, new or updated medical conditions, Type II school bus endorsement and disabled parking plate/placard eligibility.

Completed by
Licensed physician (general licensing); licensed physician, PA or NP for school bus medicals; 'medical examiner' for Sections C-E
Issued by
Vermont Department of Motor Vehicles
Format
Fillable PDF
Language
English

Vermont-licensed eye doctor reports acuity, color vision, ocular coordination and fields when DMV requires an eyesight examination to grant or keep a license.

Completed by
Vermont-licensed optometrist or ophthalmologist
Issued by
Vermont Department of Motor Vehicles
Format
Fillable PDF
Language
English

Physician or optometrist certifies the clinical diagnosis, recommended visible light transmittance and duration (4-year or indefinite) for a medical window tint permit.

Completed by
Licensed physician or optometrist
Issued by
Vermont Department of Motor Vehicles
Format
Fillable PDF
Language
English

Virginia

Multi-part report (neurological/musculoskeletal, cardiovascular, diabetes, psychiatric, etc.) the driver takes to their clinician when DMV Medical Review requests medical information; Part F is the clinician's overall assessment.

Completed by
Physician, physician assistant or nurse practitioner
Issued by
Virginia Department of Motor Vehicles
Format
Fillable PDF
Language
English

Eye doctor reports acuity, visual field and ocular conditions for a driver who failed the DMV vision test, is on vision review, wants their own doctor's test, or seeks a CDL waiver.

Completed by
Ophthalmologist or optometrist
Issued by
Virginia Department of Motor Vehicles
Format
Fillable PDF
Language
English

Medical provider certifies a condition requiring additional window sun-shading so DMV can issue a sun-shading medical authorization for listed vehicles.

Completed by
Physician, nurse practitioner, ophthalmologist, optometrist or physician assistant
Issued by
Virginia Department of Motor Vehicles
Format
Fillable PDF
Language
English

Specialists certify an intrastate CDL driver's disability (limb, diabetes/metabolic, seizure, vision under 49 CFR 391.41 categories) for a Virginia-only waiver or hazmat variance.

Completed by
Endocrinologist (diabetes), neurologist (seizure), ophthalmologist/optometrist (vision), and other specialists per disability section
Issued by
Virginia Department of Motor Vehicles
Format
Fillable PDF
Language
English

Eye doctor reports vision and bioptic telescopic lens details (make, power, date received, diagnosis, prognosis) for an applicant wishing to drive with bioptics.

Completed by
Ophthalmologist or optometrist
Issued by
Virginia Department of Motor Vehicles
Format
Fillable PDF
Language
English

Eye doctor certifies the applicant has been fitted with and used a prescription bioptic telescopic lens for at least 60 days and demonstrated required abilities.

Completed by
Ophthalmologist or optometrist
Issued by
Virginia Department of Motor Vehicles
Format
Fillable PDF
Language
English

Washington

Informe del examen de la vista

Ophthalmologist or optometrist reports acuity, fields, eye conditions and recommended re-exam frequency when DOL has reason to believe a driver's vision may affect safe driving.

Completed by
Ophthalmologist or optometrist
Issued by
Washington State Department of Licensing
Format
Fillable PDF
Language
English and Spanish

West Virginia

Examining physician reports history and details of diabetes, cardiovascular, neurological, mental illness, alcohol/drug and musculoskeletal conditions for a driver referred to DMV medical review.

Completed by
Licensed physician / licensed medical practitioner
Issued by
West Virginia Division of Motor Vehicles
Format
PDF
Language
English

Commercial-driver version of the WV medical report (adds sleep disorder); diabetes section must be completed by a board certified/eligible endocrinologist.

Completed by
Examining licensed physician; endocrinologist for the diabetes section
Issued by
West Virginia Division of Motor Vehicles
Format
Fillable PDF
Language
English

Wisconsin

Health care professional reports a driver's medical conditions and gives an opinion on whether the person is medically safe to drive, for WisDOT Medical Review.

Completed by
MD, DO, PA-C or APNP
Issued by
Wisconsin Department of Transportation, Division of Motor Vehicles
Format
Fillable PDF
Language
English

Physical examination required before WisDOT licenses a driver for a school bus (S) or passenger (P) endorsement under Trans 112.

Completed by
MD, DO, PA-C, APNP or chiropractor (DC, National Registry number required for chiropractors)
Issued by
Wisconsin Department of Transportation, Division of Motor Vehicles
Format
Fillable PDF
Language
English

Wyoming

Vision specialist reports acuity, fields (70 degrees per eye standard), progressive ocular conditions and an opinion on visual capability to drive, with restrictions.

Completed by
Qualified vision specialist (ophthalmologist or optometrist)
Issued by
Wyoming Department of Transportation, Driver Services
Format
PDF
Language
English

Qualified medical professional states whether the driver is medically capable of driving (or a lapse-of-consciousness condition is controlled), with recommended restrictions, road test or annual re-evaluation (W.S. 31-7-123).

Completed by
Qualified medical professional (physician or other qualified health care professional)
Issued by
Wyoming Department of Transportation, Driver Services
Format
PDF
Language
English

More US forms

How this list is checked

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.

Frequently asked questions

Do doctors have to report unsafe drivers to the DMV?

It depends on the state. In Pennsylvania, physicians and others authorized to diagnose or treat must report disorders that may impair driving, using the DL-13. Oregon requires the Mandatory Impairment Referral (735-7230) for severe and uncontrollable cognitive or functional impairments. California physicians report lapses of consciousness and Alzheimer's disease on the CDPH 110c to the local health officer within 7 days. New York has no mandatory physician reporting, and its DS-6 is voluntary.

Who can sign a DMV vision report?

Usually an optometrist or ophthalmologist. California's DL 62, Michigan's DA-4V and Virginia's MED 4 name one of the two, and South Carolina's 412-NC asks for a licensed eye care professional. New York's MV-619 is broader: a licensed physician, PA, RN, NP, optician, optometrist or ophthalmologist can sign it. Validity varies too. The DL 62 needs an exam within the last 6 months, while the 412-NC is valid 36 months from the exam.

What is the DC Mature Driver Fitness to Drive Certification?

District of Columbia drivers 70 and older need it at every license renewal. A licensed medical practitioner completes Section B to certify that the driver can drive safely. The driver returns the printed form with the renewal, or the certification is completed through the DMV's online transaction. While the DMV waits for it, the driver may get a 45-day temporary license.

Who sends the California DS 326 back to the DMV?

The medical professional does. DMV usually sends the DS 326 Driver Medical Evaluation to the driver with the condition of concern and a return-by date already printed. The driver completes Sections 1 to 3, and the physician, PA or NP most familiar with the driver's health completes Sections 5 to 13, then returns it to the Driver Safety office named on the form. The medical information is confidential under CVC 1808.5.