Form Mv-80u.1 - Physician'S Statement For Medical Review Unit Page 2
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1
2THIS SIDE IS TO BE COMPLETED BY YOUR PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
Physician/Physician Assistant/Nurse Practitioner: Please attach a sample of your letterhead or a voided prescription blank.
PLEASE PRINT OR TYPE
o
Patient’s Last Name
First Name
M.I.
Date of Birth (Month/Day/Year)
Male
o
/
/
Female
/
/
1. Examination Date (must be within 120 days from the date this form is submitted): _______________________
2. Condition patient is being treated for:
o
o
o
o
Epilepsy/convulsive disorder
Syncope/fainting/dizziness or
Diabetes
Sleep disorder
o
o
o
Dementia/senility/Alzheimer’s
a condition that causes unconsciousness
Head trauma/tumor
Heart condition
o
o
o
Stroke
Neurological or neuromuscular disease
Mental disorder
o
Other (please specify) ____________________________________________________________________________________
3. Symptoms, severity, and frequency of condition:____________________________________________________________________
__________________________________________________________________________________________________________
4. Date of the last episode/incident associated with this condition: ________________________________________________________
5. Have any episode(s)/incident(s) associated with this condition caused any loss of consciousness, awareness, and/or body control?
o
o
YES
NO If YES, list the dates of the episode(s)/incident(s) ____________________________________________________
__________________________________________________________________________________________________________
6. Give a brief description regarding any factors that may have caused/contributed to the episode(s)/incident(s): __________________
__________________________________________________________________________________________________________
7. To the best of your knowledge have any of the patient’s episode(s)/incident(s) resulted in a motor vehicle accident(s) and/or incident(s)?
o
o
YES
NO If YES, please give details and the dates of the episode(s)/incident(s) and related accident(s): __________________
__________________________________________________________________________________________________________
8. Tests conducted (e.g., EEG, EKG, MRI, sleep study, serum levels, etc.): ________________________________________________
9. Current treatment, medication and dosage, and /or therapy: ____________________________________________________________
__________________________________________________________________________________________________________
The following MUST be answered if the patient has a sleep disorder:
a.) Date first diagnosed with the sleep disorder:___________________________
b.) Is patient receiving treatment? _______ Type of treatment _______________________ Date treatment began:____________
c.) Is patient compliant with the treatment?_______________________________________________
10. In my medical opinion, at this time (please check one):
o
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.
o
the patient’s condition prevents the safe operation of a motor vehicle and driving privileges should be suspended.
o
the patient’s condition will not interfere with the safe operation of a motor vehicle.
Please provide further detail in the space provided or in an attached statement on your letterhead:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Physician/Physician Assistant/Nurse Practitioner’s Name (Please print in full)
Certificate or license number and state where licensed
Physician/Physician Assistant/Nurse Practitioner’s Mailing Address (include number and street)
Telephone Number (area code)
(
)
o
o
o
City
State
Zip Code
Primary care physician
Neurologist
Psychiatrist/Psychologist
o
Physician/Physician Assistant/Nurse Practitioner
o
o
Endocrinologist
Other _________________________________
Physician/Physician Assistant/Nurse Practitioner’s Signature
Date (Month/Day/Year)
ç
/
/
(Information provided by emergency care personnel is NOT acceptable.)
PAGE 2 OF 2
MV-80U.1 (5/15)
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