When the Massachusetts RMV receives information that a driver's mental health condition may affect driving, it asks for MAB118. The clinician gives the psychiatric diagnosis using DSM-5 or ICD-10, describes the extent, frequency and control of symptoms, such as orientation or dissociative episodes, any loss of consciousness, and medications, then certifies whether the patient is medically qualified to drive.
A Massachusetts-licensed medical doctor or a psychiatric nurse practitioner completes the whole form after the patient signs the release, certifying under the pains and penalties of perjury with an NPI, or Board of Registration number if there is no NPI.
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Psychiatric Evaluation Form
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A medical doctor licensed to practice in Massachusetts or a psychiatric nurse practitioner. The patient first signs the release authorizing the clinician to discuss and share relevant records with the RMV, and the clinician certifies the answers under the pains and penalties of perjury.
Item 1 asks for the psychiatric condition using a DSM-5 or ICD-10 diagnosis. Item 2 then asks for the extent, frequency and control of symptoms that could affect driving, with examples such as whether the patient is oriented in all spheres or has dissociative episodes.
Item 4 asks for the type and date of the last episode. Massachusetts treats seizure, syncope and other altered consciousness under a six-month episode-free policy, evaluated on the separate Loss of Consciousness Evaluation Form, MAB108.