Fillable Form Ds-6 - Physician'S Reporting Form printable pdf download

PHYSICIAN’S REPORTING FORM

INSTRUCTIONS:

•

Parts 1 through 3

Please provide all of the information requested in

below, and sign and date the form.

•

This form is provided for use by a physician, physician assistant, or nurse practitioner to report an individual whose driving ability may be

affected due to some physical or mental impairment.

•

This form must be completed and signed by a licensed physician, physician assistant or nurse practitioner.

•

Attach a sheet of your stationery (showing your letterhead), or a voided or blank prescription form, as additional verification for this

statement, and mail the completed form with the attached stationery or prescription to: Medical Review Unit, New York State

Department of Motor Vehicles, 6 Empire State Plaza, Room 337, Albany, NY 12228.

•

If additional assistance is needed, please contact the Medical Review Unit at (518) 474-0774, option #3. Hours are 8:30 am to 12:00 pm.

•

If your patient is an older driver, you may also visit the Resources for the Older Driver website at dmv.ny.gov/olderdriver.

Please Note:

Based on the medical information submitted, our reviewer may ask for further medical details, or may request additional

information from a pertinent sub-specialist, ex: cardiologist; neurologist

Driver License

PART 1 - DRIVER IDENTIFICATION (please print)

Number

Last

First

M.I.

Date of Birth (if not known,

Name*

give approximate age)

Street

Address

City*

State

Zip Code

* Required information

PART 2 - DESCRIPTION OF THE DRIVER’S CONDITION

Have you treated this patient?

YES

If Yes: Date of Last Examination?

Please describe the condition that you have treated or are currently treating:

Is the patient receiving medication for this condition?

YES

If Yes: Please specify the type and dosage:

In my medical opinion, (please check one):

the patient’s condition may affect the safe operation of a motor vehicle, and the patient should be evaluated by the Department of

Motor Vehicles

the patient’s condition prevents the safe operation of a motor vehicle and driving privileges should be suspended.

Please provide further detail in the space provided or in an attached statement on your letterhead:

PART 3 - IDENTIFICATION AND CERTIFICATION OF THE PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER

COMPLETING THIS REPORT

Certificate or Lic. No.

Specialty (Please specify)

Your name

(Print name in full)

State Where Licensed

Your Mailing Address

(Include Street & No.)

City

State

Zip Code

(Area Code) & Telephone Number

(

)

Date (Month/Day/Year)

Your Signature

(Sign name in full)

DS-6 (5/15)

reset/clear

Form Ds-6 - Physician'S Reporting Form

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