Physicians Report - Mva Maryland
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1
2
3
4QUESTIONS?
PHYSICIAN/HEALTH CARE
Please call: 410-768-7511
6601 Ritchie Highway, N.E.
PROVIDER REPORT
TTY FOR THE DEAF 1-800-492-4575
Glen Burnie, MD 21062
Driver Wellness & Safety
Motor Vehicle Administration
Visit our website at:
Division
For Office Use Only. Requested By:
Date Requested:
TO THE DRIVER/APPLICANT: Please complete Section 1 below.
If information is filled in by the MVA, please check to see if it is accurate and make corrections. Your
physician/health care provider completes the rest of this report. It should be returned to the MVA along with
other forms that may have been sent with the cover letter that accompanied this form. Your physician/health
care provider may choose to submit this report directly to the MVA. (Please note: Payment for any examination
and preparation of this form is YOUR responsibility.)
Per Maryland Vehicle Law Transportation Article, Section 16-118, all medical information obtained will be kept
CONFIDENTIAL and used to determine "the qualifications of an individual to drive." In some cases, "The
Administration may use information in its records for the purpose of driver safety research, provided that
personal information is not published or disclosed."
SECTION 1: GENERAL INFORMATION (To be completed by driver/applicant)
(Please Type or Print)
DRIVER/APPLICANT'S NAME
LAST
FIRST
MIDDLE
ADDRESS:
STREET
CITY
STATE
ZIP CODE
DATE OF BIRTH:
PHONE NUMBER(S):
MONTH / DAY / YEAR
DRIVER'S LICENSE NUMBER:
PHYSICIAN/HEALTH CARE PROVIDER COMPLETES SECTIONS #2 - #7
TO THE PHYSICIAN/HEALTH CARE PROVIDER:
Your patient has self-reported a medical condition that may impact his/her fitness to drive safely or has been
referred to the MVA because of a concern. There may be MVA notes below about this client and/or a request
for specific information.
Please complete sections 2-7 of this form and give it to your patient for return to the MVA, OR, return the form
by mail or fax to:
Motor Vehicle Administration
Division of Driver Wellness & Safety - Room 124
6601 Ritchie Highway, NE
Glen Burnie, MD 21062
Fax Number: 410-768-7627
MVA notes to the Physician/Health Care Provider:
DC-119 1-4 (03/2016)
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