When Louisiana's Office of Motor Vehicles suspects a physical or mental condition may affect safe driving, it issues this three-page physician report to the driver or applicant. The doctor answers condition-specific questions and states whether, from a medical standpoint, the patient can safely drive, and the OMV uses the report as a guide for its decision on the pending license.
A Motor Vehicle Analyst completes Section 1, including which condition sections apply; the patient signs the release in Section 3; the physician completes Section 2 and Section 4, with an opinion on safe driving and whether periodic reports are needed.
Download the current version from the source each time; forms change without notice.
Medical Examination Form
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Complete the sections the OMV checked in Section 1 and every section that relates to the driver's condition, in full. The form warns that incomplete forms may be rejected and could result in denial of driving privileges, and the History section must reference any illness and why the form was issued.
The physician's signature must be no more than 60 days old for the form to be valid, and the driver must return it within 30 days of the 'Date Issued' the OMV entered. Missing the 30-day deadline results in suspension of driving privileges. The current version is marked R 07/2026.
The form's note to physician cites R.S. 40:1356, which exempts a health care provider from liability for reporting to the Department of Public Safety and Corrections any visual ability, physical condition, impairment or disability that may impair a person's ability to exercise ordinary and reasonable control of a motor vehicle.