Physicians Report - Mva Maryland Page 4

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SECTION 6: FITNESS TO DRIVE SUMMARY
1.
For the conditions listed in Section 2, to your knowledge is your patient compliant with the treatment plan, including
taking of medications and office appointments? Are the conditions stable and/or improving? If your answer is "NO" to
either of these questions, please elaborate.
Based on your evaluation of this patient, do you have any concern about his/her ability to safely operate a motor
2.
vehicle?
Yes
No
Not Sure
If YES, or Not Sure, please explain:
3.
Do you think any additional assessment would help to determine your patient's medical fitness to drive?
4.
Yes
No
If YES, please explain:
SECTION 7: PHYSICIAN/HEALTH CARE PROVIDER ATTESTATION
1. How long has this patient been under your care?
2. What was the date of his/her last visit?
3. Name of Physician/Health Care Provider
(Print, type, or use stamp)
4. License Number
5. Specialty
6. Physician's Address:
7. Phone Number
8. Fax Number
9. Physician's Signature
10.
Date
-4
Physician/Health Care Provider Report
Page 4
DC-119 4-4 (03/2016)

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