Driver medical evaluation form

 · Anyone requesting that a driver be medically evaluated must complete and sign the Request for Medical Evaluation form. Anonymous requests are NOT accepted. This recommendation must only be made in the interest of public safety. Advanced age alone CANNOT be the sole reason for a medical evaluation. Learn More. Request for Medical . Driver Medical Evaluation P.O. Box , Helena, MT Phone () Fax () www.doorway.ru DriverLicense@www.doorway.ru Please PRINT (3/17) 1 of 3 Montana state authorities reserve the right to reject any form that has been altered. This form is available in alternate formats for people with disabilities. Before you Begin: As a Commercial Driver’s License holder, you are required to submit a medical report dated within the last two years, every two years. You are required to submit: A valid (original or copy) federal MER MCSA form. Medical Examiner’s Certificate Form, (MEC) MCSA These forms need to be completed by a United States (U.S.) licensed doctor of Estimated Reading Time: 2 mins.

A medical report dated within the last 2 years is required for any CDL application and then every 2 years after that. You may navigate this form with the back and next buttons at the bottom, or the labeled tabs at the top. This web form should only be used to request a replacement California Certificate of Title. Anyone requesting that a driver be medically evaluated must complete and sign the Request for Medical Evaluation form. Anonymous requests are NOT accepted. This recommendation must only be made in the interest of public safety. Advanced age alone CANNOT be the sole reason for a medical evaluation. Learn More. Request for Medical Evaluation Form. DRIVER MEDICAL EVALUATION Instructions: Print clearly and legibly. If any section of this form is incomplete, it may be returned to the medical specialist for completion. APPLICANT INFORMATION FULL NAME (Printed) DRIVER LICENSE NUMBER MAILING ADDRESS (including city, state, zip) DATE OF BIRTH.

driver reexamination and/or evaluation. information on the reverse side of this form. Signature DRIVER EXAMINATION AND/OR MEDICAL EVALUATION REQUEST. All inquiries regarding driver's license status, reinstatement of driving privileges Driver Medical Evaluation Form (to be completed by your physician). Referred to as a “DME,” the Driver Medical Evaluation (Form DS) is a 5-page medical document used by DMV Hearing Officers to evaluate the Physical and.