PennDOT medical reports, workers' comp, Medical Assistance, school and child care, sports physicals, POLST and Section 302 forms from Pennsylvania agencies.
Pennsylvania's forms come from PennDOT, the Department of Labor & Industry, the Department of Human Services, the Department of Health and the PIAA. Clinicians meet these most: PennDOT's Initial Reporting Form (DL-13) and Report of Eye Examination (DL-102), the PIAA Comprehensive Initial Pre-Participation Physical Evaluation (CIPPE), the Child Health Report (CD 51), the Pennsylvania POLST and the WIC Formula Authorization Form. This page lists all 57 Pennsylvania forms, grouped by program, from the LIBC-9 to Section 302 commitment forms.
Physicians and others who diagnose or treat must report drivers whose condition may impair driving, and PennDOT forms can be mailed, faxed, emailed or signed online through DocuSign. Most condition-specific PennDOT forms are password-protected, so request PennDOT medical reporting credentials to open them. The LIBC-9 goes to the employer or insurer within 10 days of starting treatment, then at least monthly. The PA 1663 needs an original signature; stamps are rejected. Spanish versions exist for 3 of these forms.
Mandatory provider report (history, diagnosis, treatment, findings, prognosis and return-to-work restrictions) that must accompany bills before the employer/insurer must pay.
LIBC-134Physician-marked diagram of hand/finger amputation level for specific-loss benefits under Section 306(c).
LIBC-134FPhysician-marked diagram of foot/toe amputation level for specific-loss benefits under Section 306(c).
Sworn physician statement that the employee has fully recovered from the work injury and can resume the previous occupation without limitation, supporting termination of benefits.
Face sheet for a utilization review organization's determination on the reasonableness and necessity of a provider's treatment.
Face sheet for an impairment rating evaluation (IRE) under Section 306(a.3), reporting the whole-person impairment percentage per the AMA Guides 6th edition.
PSRS-1236Treating physician's report of current disabling symptoms, findings and limitations explaining why a PSERS member cannot perform their job duties, reviewed by PSERS' contracted medical examiners without a personal exam.
Treating physician's history, findings, diagnoses, treatment and opinion on whether a SERS member can perform the duties in their position description, on which SERS' contracted reviewing physician bases a disability retirement recommendation.
Generic mandatory report of a patient's disorder or disability that may impair driving (75 Pa.C.S. 1518), used when the provider lacks history or condition-specific knowledge; PennDOT then requests details.
Records corrected/uncorrected acuity and visual field against PA minimum vision standards (67 Pa. Code 83.3; 71.3 for school bus drivers) for licensing or medical review.
Condition-specific medical report to PennDOT documenting cardiovascular or cerebrovascular disease (syncope, loss of consciousness, vertigo, dyspnea) under 67 Pa. Code 83.5, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-121Condition-specific medical report to PennDOT documenting seizure disorder/epilepsy, including seizure-free interval and waiver requests (67 Pa. Code 83.4), so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-122Condition-specific medical report to PennDOT documenting diabetes mellitus, including hypoglycemic episodes, that may affect safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-123Condition-specific medical report to PennDOT documenting other medical conditions that affect safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
Condition-specific medical report to PennDOT documenting neurological conditions affecting control of a vehicle, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-129Condition-specific medical report to PennDOT documenting loss of consciousness or awareness, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
Condition-specific medical report to PennDOT documenting cognitive impairment such as dementia that may affect safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-104Condition-specific medical report to PennDOT documenting psychiatric disorders affecting attention, judgment or behavior while driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-126Condition-specific medical report to PennDOT documenting orthopedic impairment or loss of a limb affecting vehicle control, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
DL-128Condition-specific medical report to PennDOT documenting substance use affecting safe driving, so the Bureau can decide whether the driver meets PA medical standards (67 Pa. Code Chapter 83).
Condition-specific medical report to PennDOT documenting hearing for school bus drivers (67 Pa. Code 71.3), so the Bureau can decide whether the driver meets school bus driver standards.
RDL-128ACondition-specific medical report to PennDOT documenting substance abuse history for school bus drivers, so the Bureau can decide whether the driver meets school bus driver standards.
Health care provider certifies a qualifying disability for a permanent or temporary person-with-disability parking placard (also severely disabled veteran, renewal, replacement).
Professional's report of the applicant's functional skills for using regular SEPTA buses and light rail, required with the ADA paratransit application before the functional assessment.
Physician certification of a qualifying disability (FTA criteria) for a PRT reduced-fare transit ID card for riders under 65 without Medicare.
Health care provider certifies a qualifying disability or hearing impairment for person-with-disability or hearing-impaired registration plates.
Eye doctor's report of corrected acuity, fields and functional effect of a vision disability for SEPTA Access ADA paratransit eligibility.
Physician's medical evaluation and plan of care supporting Medical Assistance payment for nursing facility (and ICF) level of care.
Physician certifies the clinical need for nursing facility level of care, used in Community HealthChoices / home and community-based waiver eligibility.
General fee-for-service request for a non-preferred drug on the Pennsylvania Statewide Preferred Drug List.
Requests fee-for-service Medical Assistance prior authorization or a program exception (1150 waiver) for outpatient services, DME and supplies.
Physician certifies terminal illness so a Medical Assistance recipient can elect the hospice benefit.
CD 51Health assessment and immunization record required for children in certified child care centers, group and family child care homes (55 Pa. Code 3270.131, 3280.131, 3290.131).
Records the mandated school physical examination (school entry, grade 6, grade 11) by a private or school physician.
Reports a private dentist's examination for the mandated school dental exams (original entry, grade 3, grade 7) and dental hygiene services program.
Initial and biennial health assessment (including TB testing) for child care staff (55 Pa. Code 3270.151, 3280.151, 3290.151).
H511.340Post-offer physical examination and TB testing record for school employees (24 P.S. 14-1418).
CIPPE Sections 1-9Required initial physical evaluation each school year before a student practices or competes at a PIAA member school, plus re-certification for later sport seasons.
Pennsylvania school immunization card recording vaccine dates, with a Statement of Exemption section for a physician-signed medical exemption or a parent religious/philosophical exemption.
Provisional-enrollment plan listing the dates each remaining required vaccine will be given, signed by the provider, so a student missing doses may attend school.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Bright pink portable medical order for CPR, medical interventions and nutrition for seriously ill Pennsylvanians.
Statutory out-of-hospital DNR order (20 Pa.C.S. 5481-5488) directing EMS not to provide CPR, optionally with a DNR bracelet or necklace.
The Section 302 application and warrant for involuntary emergency examination, including the physician's examination that decides whether the person is severely mentally disabled and in need of up to 120 hours of emergency treatment.
Petition for court-ordered involuntary inpatient, partial hospitalization, outpatient or assisted outpatient treatment (up to 90 days or continued), with the results of a current examination.
Petition for court-ordered assisted outpatient treatment under MHPA Section 304(c.2), with a clinical examination finding the person meets AOT criteria.
Court-submitted AOT treatment plan listing required services (case management/ACT), medications and provider information for a person under an AOT order.
Approved practitioner certifies that the patient has one or more (up to 10) serious medical conditions so the patient can obtain a medical marijuana ID card.
Mandatory electronic case report of a reportable disease or condition (28 Pa. Code Chapter 27) by a health care practitioner or facility to the Department of Health.
Written mandated report of suspected child abuse under the Child Protective Services Law (23 Pa.C.S. Chapter 63) following an oral report to ChildLine.
Professional certifies the applicant's disability (deaf, hard of hearing, blind, low vision, deafblind, speech, cognitive or physical) and need for specialized telephone or wireless equipment.
Physician certifies, using Social Security Act standards, that a Property Tax/Rent Rebate claimant aged 18-64 who lacks SSA/RRB proof is permanently and totally disabled.
Physician certification of a qualifying mobility, lung or cardiovascular disability so a licensed hunter can get a Disabled Person Permit to shoot from a stationary vehicle (34 Pa.C.S. § 2923).
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. Under 75 Pa.C.S. 1518, physicians and other persons authorized to diagnose or treat, including emergency room personnel, must report disorders or disabilities that may impair driving. Use the Initial Reporting Form (DL-13) when you lack the history or condition-specific details; PennDOT then asks for a condition-specific form such as the DL-120 cardiovascular, DL-121 seizure or DL-122 diabetic form. Mail, fax or email it, or sign it online through DocuSign.
An Authorized Medical Examiner: an MD, DO, PA-C, CRNP or school nurse practitioner completes Section 6, the physical evaluation and certification. The CIPPE is required each school year before a student practices or competes. Re-certification for later sport seasons in Section 8 is signed by an MD or DO, and Section 9 certifies wrestling minimum weight. The form goes to the school principal or designee. The Spanish version covers the parent and student sections.
The treating provider reports history, diagnosis, treatment, findings, prognosis and return-to-work restrictions. The report must accompany bills before the employer or insurer has to pay. File it within 10 days of starting treatment and at least monthly while treatment continues. Providers may not charge for documentation that supports a bill, but the usual fee applies to special reports the employer or insurer requests.
The POLST is a bright pink portable order covering CPR, medical interventions and nutrition, completed by a physician, CRNP or PA with the patient or decision-maker and printed on Pulsar Pink card stock. It comes in English and Spanish. The Out-of-Hospital Do Not Resuscitate Order is a statutory order directing EMS not to provide CPR. The attending physician signs item 2A, and official numbered forms, bracelets and necklaces are bought from the state's vendor.