Medical Specialist Assessment Form - Public Passenger Vehicle Driver - Roads And Maritime Services
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1
2Medical Specialist Assessment Form
Public Passenger Vehicle Driver
Important information
This form will be required to be completed if the General Practitioner is recommending you may meet the criteria for a conditional
authority. This information is being collected in order to determine your fitness to drive a public passenger vehicle in accordance with the
provisions of the Passenger Transport Act 1990 and Regulation.
If Roads and Maritime Services cannot attest to you being a fit and proper person to hold an authority, the authority may be suspended,
varied or cancelled or your application for authorisation may be refused.
You have a right to request access to the information collected by contacting Roads and Maritime. Roads and Maritime may disclose
any health information received to another medical practitioner.
Part A – Driver Details - to be completed by driver /
Part B – Referring Doctor Details to be completed by
applicant
referring doctor
Surname (family name)
Medical Practitioner name
Given names
Practice address (PO box not accepted)
Sex
Male
Postcode
Female
Telephone number
Fax number
Date of birth
/
/
day
month
year
Reason for referral (patient condition/s)
Residential address (PO box not accepted)
Postcode
Contact phone number
Medical Practitioner Signature
Driver licence number
Authority number
Date
/
/
day
month
year
Authority type
Bus
Taxi
Motorcycle
Part C – Specialist Summary to be completed by
Specialist Medical Practitioner (full details to be
Private Hire vehicle
4WD
completed on page 2)
The driver (applicant) detailed in Part A:
Driver / applicant declaration
I consent to my medical practitioner providing my health
Meets the criteria for an unconditional driver authority
information to Roads and Maritime, or to a medical
Meets the criteria for a conditional driver authority
practitioner nominated by Roads and Maritime Services.
Further, I give authority to Roads and Maritime Services to
I recommend future review:
Yearly
obtain details of any matter which may assist in determining
in
Months
whether I meet the medical criteria outlined in the publication
Assessing Fitness to Drive (Commercial and Private Vehicle
in
Years
Drivers) 2012.
Does not meet the criteria for a conditional driver
Signature
authority (as per AFTD March 2012)
Specialist Medical Practitioner signature
Date
/
/
Date
day
month
year
/
/
day
month
year
continued page 2
Enrolment Processing Unit
Level 4, 16 - 18 Wentworth Street Parramatta NSW 2150
Locked Bag 5085, Parramatta NSW 2124
1800 227 774
T 02 9689 8888
F 02 9689 8813
E licensing@transport.nsw.gov.au
Catalogue No. 45071752 Form No. 1690 (03/2016) ABN 76 236 371 088
Page 1 of 2
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