Nebraska's Department of Motor Vehicles uses this two-page statement to decide whether a driver or applicant with a neurological, psychiatric, substance use, diabetic or cardiac condition can be licensed. The examining physician completes the relevant condition sections and a required general statement on mental and physical capability, and the report is not valid more than 90 days after the exam.
The applicant signs the authorization at the top before the exam; the examining physician, an M.D. or D.O., completes the condition sections and general statements and signs.
Download the current version from the source each time; forms change without notice.
Statement of Physician
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
The form is not valid more than 90 days after the examination date, and the date of examination must be completed. It can be mailed, faxed or emailed to the Nebraska DMV using the details at the top of the form, by the physician or the applicant.
The signature block calls for an M.D. or D.O., who also records type of practice and contact details. The applicant signs an authorization at the top before the exam, allowing the doctor to release information about their physical and psychological condition and history to the DMV.