Connecticut DMV uses this 4-page medical form when a patient has been referred over their ability to drive safely, and DMV may refer the result to its Medical Advisory Board. The examiner gives an overall fitness finding, then completes condition-specific subsections for cardiology, diabetes, neurology, orthopedics, psychiatric and substance use, and respiratory and sleep disorders.
The patient completes Section A, with an optional authorization for DMV to discuss the case with named people. A licensed physician, PA or APRN completes Section B and every subsection of Section C, signing each.
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Medical Form
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A licensed physician, physician assistant or APRN completes Sections B and C based on a personal examination within 90 days. The patient completes Section A. Each condition-specific subsection carries its own certification, signature, license number and examination date.
Under Sections 14-46b and 14-46c of the General Statutes, DMV may refer the report to its Medical Advisory Board, which can request more medical information. DMV then makes the final decision on the patient's ability or privilege to hold an operator's license. Good-faith reports are protected from civil action.
Yes. The respiratory section asks whether the patient can exhale 1000 cc of air in one continuous breath for an ignition interlock device. The orthopedic section lets you restrict the license to a mechanical aid, prosthetic aid or automatic transmission under Section 14-36a.