Form 20-1900 - Driver Medical Evaluation - Montana Department Of Justice
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1
2State of Montana
Department of Justice
Motor Vehicle Division
DRIVER MEDICAL EVALUATION
Name (Last, First, Middle)
Driver’s License No.
Birth Date
Street address
City
ZIP
Daytime or home phone number
RELEASE OF INFORMATION BY PATIENT
I hereby authorize my physician or hospital to answer any questions from the Motor Vehicle Division, or its employees relating to my
physical or mental condition, and/or drug and/or alcohol use or abuse, and to release any related information or records to the Motor
Vehicle Division or its employees. Any expense involved is to be charged to me and not the State of Montana.
I hereby authorize the Motor Vehicle Division to receive any information relating to my physical or mental condition, and/or drug and/or
alcohol use or abuse, and to use the same in determining whether I have the ability to operate a motor vehicle safely.
Signed: X
Date:
Witness:
A. INTRODUCTION TO PHYSICIAN
Motor Vehicle Division records indicate your patient may have a condition that could affect the safe operation of a motor vehicle.
With your assistance, we hope to resolve the matter with a minimum of inconvenience to all concerned.
Your experience and knowledge of the patient’s condition, results of medical examinations and treatment plans, will be of great value
in assisting the department to determine a proper licensing decision. PLEASE ANSWER ALL QUESTIONS on this form that are
applicable to your patient’s condition. A physician reporting in good faith is immune from liability, civil or criminal penalties under
Montana law §37-2-311, 37-2-312, MCA. The department has sole responsibility for any decision regarding the patient’s driving
qualifications and licensure. The department will also consider non-medical factors in reaching a decision.
:
The above individual is being referred to you due to
B. DIAGNOSIS
Is the condition:
Improving
Stable
Worsening or deteriorating
Subject to change
How long has this person been your patient?
Date of last examination:
How long has control been maintained?
Is your patient under a controlled medical program? Yes
No
Is the patient adhering to the medical regimen?
Yes
No
If no, please explain:
C. MEDICATIONS
Please list any medication currently prescribed:
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