Try for free

PennDOT DL-104 Psychiatric Medical Reporting Form

Pennsylvania clinicians use this condition-specific form to report a driver whose psychiatric disorder may affect attention, judgment or behavior behind the wheel. PennDOT reviews it against the medical standards in 67 Pa. Code Chapter 83, then decides whether the driver keeps the license, gets a restriction or examination, or has the driving privilege recalled.

Who completes it

The treating physician or other health care provider completes the whole form; the driver has no section. Pennsylvania's reporting duty covers physicians, chiropractors, physician assistants and certified registered nurse practitioners.

Submitting and payment

How to submit it
Mail it to PennDOT's Bureau of Driver Licensing, fax or email it to the medical unit, or complete and sign the online version; the law requires a written report within 10 days.

Good to know

  • PennDOT's mental criteria include inattentiveness to driving from preoccupation, hallucination or delusion; contemplation of suicide, as in acute or chronic depression; and excessive aggressiveness or disregard for the safety of self or others.
  • The PDF is password-protected. Health care personnel need a PennDOT medical reporting login, requested through the Medical Reporting Forms page, to open it.
  • School bus drivers are reported on DL-104A, the Chapter 71 psychiatric form, rather than DL-104.
  • Reports are not required when the condition is expected to last less than 90 days.

Get the official form

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

General Psychiatric Form

Official pagePDF

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 I need a password to open PennDOT's DL-104?

Yes. PennDOT keeps its condition-specific forms behind a medical reporting login, so health care personnel must request credentials before opening the PDF. An online version can be completed and signed electronically instead, and the general DL-13 Initial Reporting Form is meant for clinicians who lack detailed knowledge of the condition.

What happens after I report a psychiatric condition to PennDOT?

PennDOT reviews the report within 15 days. It may find the driver competent and take no action, send the driver forms requesting more medical information with 45 days to comply, or deem the driver medically incompetent and recall the privilege seven days after the notice is mailed. Restrictions or a driver's exam are also possible.

Am I protected if I report a patient to PennDOT?

PennDOT states that providers who report are immune from civil or criminal liability, while providers who fail to meet the legal duty may be convicted of a summary offense. HIPAA does not apply to medical reporting to PennDOT, and reports are confidential and used only for licensing decisions.