Oregon requires certain physicians and health care providers to report a patient whose severe and uncontrollable cognitive or functional impairment affects safe driving, and this is the form they use. It records the underlying condition, checkboxes for vision, strength, coordination, attention, memory and loss-of-consciousness impairments, and how they affect driving. A mandatory report can lead to immediate suspension of driving privileges.
The reporting clinician completes the whole form: the patient's primary care provider (including hospitalists), a specialist physician, PA or NP seeing the patient on referral, a referred health care provider, or an emergency care clinician.
Download the current version from the source each time; forms change without notice.
Mandatory Impairment Referral
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.
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The form lists four groups: the patient's primary care provider, including hospitalists during inpatient care; a physician, physician associate or NP giving specialist care on referral for the impairment; a referred health care provider such as a chiropractor, NP, OT, PT, optometrist, PA, podiatrist or mental health provider; and clinicians providing emergency care.
Relevant supporting information: chart notes, pertinent test results, medications that may interfere with driving, recorded visual acuities and field maps, and effects of problem drug, alcohol or inhalant use. Provider memos or letters may be included, and DMV cannot act on a diagnosis alone.
Reports are confidential and used only to judge whether the person can drive safely, and the form states that submitting it complies with HIPAA. If the driver requests a hearing, the report and related documents become hearing exhibits and can no longer be kept confidential.