Form Mvd - 10124 - Medical Report - Motor Vehicle Division, State Of New Mexico (Page 2 of 2) in pdf

MEDICAL REPORT FORM: INSTRUCTIONS FOR PHYSICIANS

The Health Standard Advisory Board of the MVD will review the Medical Report and make

recommendations to the MVD with respect to the patient’s application of licensure or for renewal. The

final decision on licensure, renewal of licensure, or denial is the responsibility of the MVD. Please

make sure all pertinent information is available to the HSAB and the MVD in order to achieve a just

and equitable decision.

The following instructions apply to physicians completing the MVD Medical Report Form

1. Applicant Name: Please start with LAST NAME and print all information neatly.

2. Address: Please complete all items including Social Security Number (The social security

number is confidential and is NOT printed on the driver’s license).

3. Disease or Condition: please check off ALL that apply.

4. Physician: Please indicate follow-up with patient: duration, frequency, most recent exam

5. Diagnoses: please list SIGNIFICANT DIAGONOSES ONLY (those that do or might affect

driving). Please do NOT include such diagnoses as Thyroid, COPD, Cancer, etc., unless they

actually affect the applicant’s ability to drive safely. Be sure to indicate dosage and level of

control. Continue list on another sheet of paper if needed.

6. Control: Please indicate if disease or condition is controlled, and possible hazard to driving.

7. Tests: Please list SIGNIFICANT TESTS and RESULTS and DATES. For DIABETICS it is

important to list the HgbA1C (with date). For CARDIACS, result of ECG, Stress, Cardiac

Cath., etc. For STROKES, AMPUTATIONS, NEUROLOGICAL, etc., important results.

8. Opinion on Driving: If the patient is not capable of driving safely, please explain, continuing

the explanation on a separate sheet of paper as needed.

9. Restrictions? Please specify any driving restrictions that are required for the patient. This

information is important when an officer of the law stops the patient for cause.

10. Recommended licensing intervals : Please indicate your recommended length for the interval

to the next license renewal date. This should be based on the stability of the medical condi-

tion. The standard interval is 4 years, with shorter terms to be chosen normally for unstable

patients requiring more frequent evaluation. A licensing interval of 6 months should only be

recommended for serious conditions. A licensing interval of greater than 4 years is not al-

lowed. DO NOT complete the sections marked “Medical Advisory Board” or “MVD Office”.

11. Physician’s Name: Please print NEATLY, complete ALL sections, and observe the following

requirements:

Only MD or DO physicians may sign the form. When another professional completes

the form (CFNP, CNP, PA-C) the patient’s physician must countersign the Medical

Report.

Please provide physician’s License Number.

Form Mvd - 10124 - Medical Report - Motor Vehicle Division, State Of New Mexico Page 2