New Jersey physicians and emergency rooms use this one-page report to notify the Motor Vehicle Commission's Medical Fitness Review Unit about a patient's seizure or loss-of-consciousness episodes for medical review. It records onset, frequency in the past year, the last occurrence, any EEG and the resulting classification.
The reporting physician or emergency room clinician completes and signs the whole form, including their specialty.
Download the current version from the source each time; forms change without notice.
Medical Emergency Report
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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New Jersey requires physicians to report recurrent loss of consciousness under N.J.S.A. 39:3-10.4, and MR-4, the Medical Emergency Report, is the form for it. It goes to the MVC's Medical Fitness Review Unit by mail or email.
Patient identification including driver license number, the date of onset, frequency during the past year and date of last occurrence, whether an EEG was performed with its date, place, results and reader, the resulting classification, remarks, and the reporting clinician's signature and specialty.