Request For Medical Evaluation Form printable pdf download

REQUEST FOR MEDICAL EVALUATION

Please FAX to 857-368-0802 and mail original to: Medical Affairs, P.O. Box 55889, Boston, MA 02205

This form is used to report a person you believe is no longer physically or medically capable of operating a

motor vehicle safely. Please provide as much information as possible.

Information about the Driver: (required)

Last Name: _______________________________ First Name: _____________________________________

License or Social Security Number: _____________________________ Date of Birth: ______/______/______

Current Address: __________________________________________________________________________

__________________________________________________________________________

Please briefly describe reason for concern: ______________________________________________________

________________________________________________________________________________________

By signing this form, I certify to the best of my knowledge and under the pains and penalties of perjury that the

above information is true:

Signed: ____________________________________________________

Date: _____/______/______

Name: ____________________________________________________ Phone: ________________________

(please print)

FOR LAW ENFORCEMENT or HEALTH CARE PROVIDER ONLY

(If not law enforcement or a health care provider, please leave this section blank.)

Please check one of the following categories:

I hereby certify that in my professional opinion and to a reasonable degree of certainty,

D D D D The person named above is NOT medically qualified to operate a motor vehicle safely.

D D D D I am unable to determine driving ability and I recommend the person undergo a competency

road examination.

D D D D The person may require adaptive equipment and/or an assessment for appropriate license

restrictions via a competency road examination.

Please complete applicable areas:

Signature: ___________________________________________________________ Date: ____/____/______

Name: ____________________________________________________ Phone: ________________________

(please print)

Profession / Title: __________________________________________________________________________

(e.g., Law Enforcement or Health Care Provider)

Place of Employment: ______________________________________________________________________

(e.g., Saugus Police Dept. or Boston Medical Center)

Medical Professionals, please provide Board of Registration Number: ______________________________

Law Enforcement Professionals:

Was the driver cited by you? D D D D No

D D D D Yes, Citation Number: ___________________________________

Health Care Provider Definition: A registered nurse, licensed practical nurse, physician, physician’s assistant,

psychologist, occupational therapist, optometrist, ophthalmologist, osteopath, physical therapist, or podiatrist who is a

licensed health care provider under the provisions of M.G.L., Chapter 112.

T21788-0712

Request For Medical Evaluation Form