Form 2 - Medical Evaluation For Driver License Mail Renewal Application

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Medical Evaluation for
Driver License Mail Renewal
Application
(Form 2)
P.O. Box 201430 Helena, MT 59620-1430  Phone (406) 444-4590  Fax (406) 444-7623 
Patient’s Legal Name (Last, First, Middle)
Patient’s Driver License No.
Patient’s Birth Date
Patient’s Mailing Address
City
State
Zip
Daytime Phone #
INTRODUCTION TO PHYSICIAN:
Montana State Law, MCA 61-5-111(3)(d)(ii), requires a medical evaluation form to be completed by a licensed physician.
Pursuant to Montana State Law, MCA 61-5-207, REEXAMINATION OR MEDICAL EVALUATION – WHEN REQUIRED, a Montana driver
license may be denied if it is determined that additional medical evaluation or license testing is required.
Please indicate, to the best of your knowledge, if your patient may have any conditions that could affect the safe operation of a motor vehicle.
Complete the sections below and return to patient.
1. IMPAIRMENTS THAT ARE PRESENTLY SHOWN BY YOUR PATIENT:
Sporadic loss of conscious awareness
Memory Loss
Impaired motor function
Alzheimer’s disease
Reaction, or impairment due to change in medication or dosage
Confusion
Neurological or neuromuscular disease
Other dementia
Diminished concentration
Other metabolic disorder
Diminished judgment
Comments:
2. IS YOUR PATIENT PHYSICALLY AND MENTALLY CAPABLE OF SAFELY OPERATING A MOTOR VEHICLE, IN YOUR OPINION?
Yes
No
If NO, please describe:
3. DO YOU RECOMMEND ANY DRIVING RESTRICTIONS OR ADAPTIVE EQUIPMENT FOR YOUR PATIENT?
Yes
No
If YES, please describe:
LICENSED PHYSICIAN/PROVIDER:
Signature:
Name (printed):
Date:
Type of Practice or Medical Specialty:
Address (include city, state, zip):
Telephone Number:
Medical License Number:
20-1900B (2/10)

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