Drivers in the Kentucky Ignition Interlock Program who have a medical condition that keeps them from using the device can ask to be considered for a lower air volume setting with this physician statement. The physician gives the diagnosis, the pulmonary function test performed and its date, and says whether the patient could blow into the device at 1.2 or 1.0 liters per breath.
The driver completes Sections 1 and 2, contact details and an authorization for the physician to examine and release records. A physician completes Section 3 and signs with their physician index number.
Download the current version from the source each time; forms change without notice.
Breath Alcohol Ignition Interlock Physician Statement
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Based on your exam and the pulmonary function test, you answer whether the patient should be capable of blowing into an ignition interlock device at an air volume setting of 1.2 liters per breath, and separately at 1.0 liters per breath. Attach the test results.
Yes. It must accompany the TC 94-175 Kentucky Ignition Interlock Program Application, unless the driver is already an approved program participant. The driver signs an authorization allowing you to release medical information to KYTC and the District Court.