Drivers ordered to install an ignition interlock device in California can ask for a medical exemption if a condition keeps them from giving the required breath sample. The provider most familiar with their health certifies that they can't meet the minimum of 1.5 liters of breath for the initial test and random retests, and DMV uses the form to decide eligibility.
The driver completes and signs Sections 1 and 2, the driver information and acknowledgement and consent. The medical provider completes Section 3 with name, specialty, license number and contact details, and Section 4, initialing the opinion and signing under penalty of perjury.
Download the current version from the source each time; forms change without notice.
Ignition Interlock Device (IID) Medical Exemption Request
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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That, based on the driver's health history and current condition, they are unable to meet the minimum breath sample needed to operate an ignition interlock device: 1.5 liters for the initial test and for random retests while driving. You initial that statement and sign under penalty of perjury.
The driver is exempt from installing the device but will not be granted a restricted driving privilege. Instead, only the suspension or revocation option remains. The driver acknowledges this in Section 2 before the provider completes the medical sections.