Pennsylvania clinicians report cognitive impairment, such as dementia, that may affect a patient's safe driving on this PennDOT form. Cognitive impairments are among PennDOT's mental criteria, and the Bureau of Driver Licensing reviews the report against 67 Pa. Code Chapter 83 before deciding on restrictions, a driver's exam, recall of the license or no action.
The treating physician or other health care provider who diagnosed or manages the cognitive impairment completes the whole form; there is no section for the patient.
Download the current version from the source each time; forms change without notice.
Cognitive Impairment 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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. PennDOT states that HIPAA regulations do not apply to medical reporting to PennDOT and that no individual consent is needed. Reports are confidential and used solely to determine whether the person can drive safely, and reporting providers are immune from civil or criminal liability.
When PennDOT needs more information, it sends the driver the necessary forms and allows 45 days to comply. A driver who does not comply has the license suspended within 30 days for non-compliance.
Request health care personnel credentials from PennDOT's Medical Reporting Forms page; the condition-specific forms open only with a medical reporting login. The online version lets you complete and sign the report electronically instead of using the PDF.