The Kansas Division of Vehicles' Medical/Vision Unit uses this 2-page form to learn whether a patient can safely operate a motor vehicle. The medical or psychological professional reports any condition that could affect driving, loss of consciousness or seizures, specialist referral, comments and recommended restrictions, and answers whether a drive test, an annual medical report or a vision exam is needed.
The patient completes the General Information and History section and signs the release. A medical or psychological professional, such as a physician, APRN, PA or psychologist, completes the rest, giving name, license number, specialty and signature.
Download the current version from the source each time; forms change without notice.
Kansas Division of Vehicles Medical 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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The information must come from an examination within the last 90 days. If the patient recently had a loss or alteration of consciousness, the exam date must be a full six months after the last occurrence, and the form asks whether a six-month revocation is required.
Yes. To remove a restriction previously requested by a physician, check that restriction box and write R beside it. The form also lets you add up to 6 restrictions, request an adaptive equipment test permit, or recommend a drive test or annual medical reports.