New York DMV's Medical Review Unit uses this two-page statement to decide whether a driver with a medical, physical or mental condition can keep driving, particularly after loss of consciousness or body control. The driver fills in page 1 and brings it to the treating clinician, who completes page 2 with the condition, episode history, tests, treatment and an opinion on safe driving.
The driver completes page 1: identity, client ID number and which provider is treating them. A physician, physician assistant or nurse practitioner completes and signs page 2; information from emergency care personnel is not accepted.
The driver prints their last name, first name, middle initial, sex, date of birth, mailing address, client ID (driver license) number, any other names used and a daytime phone number. They then check who is treating them: primary care physician, nurse practitioner, physician assistant, specialist, or psychiatrist or psychologist, and write in the provider's name. Ask the patient to finish this page before your visit so the identifiers match DMV's record.
Page 2 is headed for completion by the physician, physician assistant or nurse practitioner. Repeat the patient's last name, first name, middle initial, date of birth and sex, printed or typed. The header also asks the clinician to attach a sample of their letterhead or a voided prescription blank to the statement before it is returned.
Enter the examination date, which must be within 120 days of when the form is submitted. Check each condition being treated: epilepsy or convulsive disorder, syncope or a condition causing unconsciousness, diabetes, sleep disorder, dementia, head trauma or tumor, heart condition, stroke, neurological or neuromuscular disease, mental disorder, or other. Then describe the symptoms, their severity and how often they occur.
Item 4 asks for the date of the last episode or incident associated with the condition. Item 5 asks whether any episode caused loss of consciousness, awareness or body control; check Yes or No, and if Yes, list the dates of the episodes or incidents. Taking these dates from the chart keeps them consistent with the rest of the record.
Item 6 asks for a brief description of any factors that may have caused or contributed to the episodes or incidents. Item 7 asks whether, to the best of your knowledge, any episode resulted in a motor vehicle accident or incident; if Yes, give details and the dates of both the episode and the related accident.
Item 8 lists the tests conducted; the form's own examples are EEG, EKG, MRI, sleep study and serum levels. Item 9 records current treatment, medication and dosage, or therapy, followed by the date treatment began. Medication names and doses should match the current medication list.
The form says this item must be answered whenever the patient has a sleep disorder. Part a asks for the date the patient was first diagnosed with the sleep disorder. Part b asks whether the patient is receiving treatment and the type of treatment. Part c asks whether the patient is compliant with the treatment.
Check one opinion: the condition may affect safe operation of a motor vehicle and the patient should be evaluated by DMV; the condition prevents safe operation and driving privileges should be suspended; or the condition will not interfere with safe operation. Add further detail in the space provided or in an attached statement on letterhead. Print your name, license number and state, mailing address and phone, mark your provider type, then sign and date.
Download the current version from the source each time; forms change without notice.
Physician's Statement for Medical Review Unit
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.
Sources for this guide
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Yes. Page 2 is written for a physician, physician assistant or nurse practitioner, and the signature block lets the signer identify as a primary care physician, neurologist, psychiatrist or psychologist, endocrinologist, or other provider. What DMV will not accept is information provided by emergency care personnel, a restriction printed on both pages of the form.
The statement must be based on a current examination performed within the last 120 days from the date the statement is submitted to DMV. Item 1 on page 2 records the examination date, and the form repeats the 120-day limit beside it. An older visit means the patient needs a new examination before the form is completed.
On DMV's Medical Review page, the DS-6 is the form a physician uses to report on their own initiative that a patient's condition can affect driving. The MV-80 is the physician's statement brought to a re-evaluation interview. The MV-80U.1 is the statement for the Medical Review Unit about loss of consciousness or body control and related conditions.
The Medical Review Unit, which uses board-certified physicians as medical consultants, reviews the statement. It may request additional information from the clinician who completed it or from a qualified specialist. DMV can suspend a license when requested documentation is late or unacceptable, and after a crash caused by loss of consciousness the license stays suspended until documentation is reviewed.