Michigan's Department of State sends this six-page statement when a medical condition or a loss of consciousness may affect someone's safe driving, usually as part of a driver assessment reexamination. The driver completes the history and questions. The medical provider then answers questions on driving capability, cognitive and functional testing and restrictions, and documents each diagnosis, treatment and prognosis.
The driver completes Sections 1 to 3. The examining provider completes Sections 4 to 6: an MD or DO (including psychiatrists), physician assistant, psychologist or nurse practitioner may certify, and a nurse practitioner's statement needs the supervising physician's signature.
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Physician's Statement of Examination (Medical Statement of Examination)
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Yes, with a countersignature. The Department of State says the statement may be certified by an MD or DO, including psychiatrists, a physician assistant, a psychologist or a nurse practitioner. When a nurse practitioner completes the exam, the supervising physician must also sign the Section 6 certification.
The answers must be based on an examination within three months of the provider's certification, and the Department must receive the form within three months after it is signed. The provider certifies having reviewed the driver's Sections 1 to 3 and completed the medical sections from the history and an examination.
No. The certification states that the decision to grant, suspend or reinstate driving privileges rests solely with the Department of State, which may weigh other facts. The provider's answers and recommended restrictions inform the Driver Assessment analyst, who may also require vision screening, a knowledge test or an on-road test.