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Nebraska Medical Hardship Driving Permit Application

A Nebraska driver whose license was revoked under the point system can apply for a 90-day permit to drive to and from medical treatment. The treating physician's notarized affidavit on page 4 confirms the patient must drive for their medical needs, that treatment will not impair driving, and that the treatment days, hours and routes the patient listed are correct.

Who completes it

The applicant completes and signs the application before a notary, including treatment days, hours and routes; the treating physician completes and signs the Physician's Affidavit, also before a notary. A separate application is needed for each doctor.

Submitting and payment

How to submit it
The applicant sends the application with the SR-22 and the license, if not already surrendered, to the DMV's Medical Hardship Driving Permit Program by mail, fax or hand delivery, not to a local exam station.
Who pays
Permit fees are the driver's, paid to the County Treasurer when the permit is issued after the DMV's authorization letter; the form sets no fee for the physician's affidavit.

Good to know

  • The permit covers only travel between home or work and a hospital, clinic, doctor's office or similar location; it cannot be used for shopping, probation meetings, school or a commercial vehicle.
  • Law enforcement checks the days, hours and routes on the application if the driver is stopped, which is why the physician confirms Sections 6 and 7.
  • The permit lasts 90 days, then the driver must reapply, and it is revoked if the driver is convicted of an offense that assesses points.
  • Provisional Operator's Permit holders are not eligible, and drivers must notify the DMV of any change or end of treatment by filing a revised application.

Get the official form

Download the current version from the source each time; forms change without notice.

Application for Nebraska Medical Hardship Permit

Official pagePDF

Fill it with Vero

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.

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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.

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Frequently asked questions

Does the physician's signature need to be notarized for Nebraska's medical hardship permit?

Yes. The Physician's Affidavit must be signed in the presence of a notary public, and the signature must match the physician name given in Section 10. The applicant's own signature is notarized separately on page 3 of the application.

What does the physician confirm on the Nebraska medical hardship application?

Four yes-or-no statements: the patient needs to drive as a condition of their medical needs, treatment will not impair their ability to drive, the days and hours in Section 6 are correct, and the routes or areas in Section 7 are correct. A separate application is needed for each treating doctor.

How long does a Nebraska medical hardship permit last?

Ninety days. At expiration the driver may reapply in the same way. The permit is only for drivers whose license was revoked under the point system, and the DMV revokes it if the driver is convicted of an offense that assesses points.