Bureau of Motor Vehicles - DRIVER MEDICAL EVALUATION

Bureau of Motor Vehicles, 101 Hospital Street, Augusta, ME 04333-0029 TTY Users call Maine relay 711 1

State of Maine

Bureau of Motor Vehicles

DRIVER MEDICAL EVALUATION

THIS SECTION TO BE COMPLETED BY DRIVER (Please print) FOR QUESTIONS call (207)624-9000, ext. 52124

Name ________________________________________________ Date of Birth ________________________

Address ______________________________________________ License/History Number _______________

_____________________________________________________ Telephone __________________________

INFORMATION BELOW TO BE COMPLETED BY APPROPRIATE MEDICAL OR PARAMEDICAL PROFESSIONAL

1. Reason for Report: To provide information to the Secretary of State regarding a possible physical, emotional or

mental condition which could affect the driver’s ability to safely operate a motor vehicle. Your report will be

advisory and used to assist in determining eligibility for a driver’s license.

2. A Clinician Acting In Good Faith Is Immune from damages claimed as a result of filing a Driver Medical

Evaluation pursuant to 29-A MRSA Section 1258 (6). The driver’s signature is not required to submit this form.

3. Please Refer To Functional Ability Profiles (FAP) to assist you in completing this form. The rules are available at,

http://www.maine.gov/sos/bmv/licenses/medical.html. Please provide Profile Level(s) for specified

condition(s) or any other condition that may affect the driver’s ability to safely operate a motor vehicle.

4. If You Have Any Questions please call the Bureau of Motor Vehicles, Medical Section, at (207)624-9000, ext.

52124, or access the website; http://www.maine.gov/sos/bmv/licenses/medical.html

DIAGNOSIS FAP PROFILE LEVEL

THIS SECTION MUST BE COMPLETED – PLEASE PRINT OR TYPE CHECK ONE BOX PER DIAGNOSIS

1 2 3A 3B 3C

_________________________________________________

_________________________________________________ i

_________________________________________________

NOTE: For any Alteration/Loss of Consciousness, Seizure, Stroke, or Hypoglycemia episode requiring 3

party

intervention, please give date(s) and describe most recent episode(s)__________________________________________

For Chronic Respiratory Disease, please provide oxygen saturation and indicate if measured while using oxygen or not.

O2 Saturation______________________ On room air On oxygen

For Hypoglycemia profile level 3b, please check appropriate sub-category. 3b.i. 3b.ii.

For Prescription Medications and/or Opioid Replacement Therapy and patient meets criteria for profile level 3c, please

check appropriate profile level sub-category. 3c.i. 3c.ii.

For Substance Abuse profile level 3b, please document how long the patient has been substance free. ________________

CLINICIAN COMMENTS

(Please document if you are recommending restrictions, road test, or suspension of license, and describe deficits or impairments

with potential to affect safe driving. Attach additional documentation if needed.)

Please proceed to next page…

MD-FR-24 (CR-24) Rev 05/01/23

Bureau of Motor Vehicles, 101 Hospital Street, Augusta, ME 04333-0029 TTY Users call Maine relay 711 2

MEDICATIONS currently prescribed: (may attach med list)

Reliability in taking medications

Good Fair Poor Unknown No medication prescribed

Has patient reported or demonstrated any side effects from current medication(s) which would interfere with safe

operation of a motor vehicle? NO YES, please describe________________________________

CERTIFICATE OF EXAMINATION (May be submitted without the patient signature)

Being duly licensed to practice in the state of ______________ I hereby certify that I have examined this applicant.

_______________________________________ ______________________________________________

(Clinician’s signature) (Degree & Specialty)

_________________________________________ ______________________________________________

(Clinician’s name printed or typed) (Address)

_______________________________________ ______________________________________________

(Office phone number) (Office fax number)

_______________________________________ ______________________________________________

PROVIDE DATE OF LAST ASSESSMENT (Signature Date)

(Must be within past 12 months or as specified by BMV)

Reply to: Bureau of Motor Vehicles, Medical Section

29 State House Station

Augusta, Maine 04333-0029

Telephone: (207)624-9000 ext. 52124

E-mail: medical.b[email protected]

Fax: (207) 624-9319

For assistance or to get a copy of the Functional Ability Profile rules, please go to:

http://www.maine.gov/sos/bmv/licenses/medical.html or

Call the Medical Section at (207)624-9000, 52124.

DRIVER AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize the release of my medical history by _________________________________________ to the

Secretary of State, Bureau of Motor Vehicles. I understand that this information may be shared with any qualified

health care professional submitting information pertaining to the disclosed medical history for the purpose of

determining my eligibility for a driver’s license.

PATIENT SIGNATURE _________________________________ DATE_____________________________________

E-MAIL _____________________________________________ PHONE NUMBER____________________________

FOR QUESTIONS OR CONCERNS, call (207)624-9000, ext. 52124, or access the website:

http://www.maine.gov/sos/bmv/licenses/medical.html

____________________________________________________________________________________________

Veterans please visit the Bureau of Veterans’ Services website at http://www.maine.gov/veterans for information on

state and federal benefits your military service may have earned you.