Pennsylvania clinicians use this PennDOT form to report diabetes mellitus, including hypoglycemic episodes, that may affect a patient's ability to drive safely. The Bureau of Driver Licensing reviews it against the Chapter 83 medical standards, where unstable diabetes is a listed criterion, and decides whether to restrict, recall or restore the driving privilege.
The treating physician or other health care provider who manages the patient's diabetes completes the whole form.
Download the current version from the source each time; forms change without notice.
Diabetic Form
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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According to PennDOT's forms page, drivers eligible for restoration must complete follow-up exams that include an HbA1C test and a vision screening. Those exams may be required more often if the treating health care provider recommends it.
No. PennDOT states the waiver will only be granted if the treating health care provider submits written certification, so the clinician who manages the diabetes plays a direct part in the decision.
PennDOT's criteria list unstable diabetes, and the reporting duty covers conditions that could impair the ability to drive safely, excluding those expected to last less than 90 days. Reports must give the driver's full name, address and date of birth within 10 days.