Commercial driver license intrastate medical waiver application. Required to have a dot medical cardcertificate excepted interstate. The mer will be completed online at the center and does not need to be printed and completed. Submit only the medical doctor or osteopathic physician evaluation page, located at the end of this form, to employer for drivers 70 years of age and older authority.
Many drivers who file a medical examination report mv3644 or certificate of vision examination by competent authority mv3030v are found to meet medical standards for licensing. Medical doctor plates can only be registered by massachusetts residents who are actively registered by the board of registration in medicine. Fill out your medical self certification form and include a copy of your dot physical card. Fmcsa form mcsa5875 us department of transportation. Department of transportation federal motor carrier safety administration. Drivers conversations you should have with your doctor. Cdl drivers dot medical exam form 649f pdf 9 pages. Dot physical exam forms are the main forms used to guarantee that the person is able to take the exam. Medical certification requirements as part of the commercial. A cdl skills exam must be taken at one of the authorized cdl driving skills exam. Medical consent form 5 documents dot physical form 2 documents bsa medical form 3 documents medical application form 4 documents generic authorization medical release form 8 documents immunization record 5 documents medical records request form 8 documents health and safety policy statement 3 documents hc1 form 2 documents.
Use this form to document verification and place this form in the drivers qualification file. Dot physical form fill online, printable, fillable, blank pdffiller. Cardiovascular dl120a cardiovascular formdl705 cardiovascular waiver 71. The information that will be provided in this document is as follows. Insulintreated diabetes mellitus assessment form, mcsa5870. Cdl drivers dot physical exam form 649f pdf medical card. If you dont hold an intrastate medical waiver, submit your cdl medical documents by. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate mec, form mcsa5876. Dec 22, 2015 cdl drivers dot medical exam form 649f pdf1 updated 1162015.
Once your physical is complete, the medical examiner will give you a medical examiners certificate form mcsa5876. This package has been removed due to the update of the diabetes standard. Medical examiners name address return to medical examiners office for follow up on telephone number if meets standards, complete a medical examiners certificate as stated in 49 cfr 391. Commercial vehiclescdl iowa department of transportation. If a state accepts mailed in medical certificates, faxed medical certificated, andor emailed medical certificates. Wisconsin dmv official government site medical exam. Medical examiners certificate mec, form mcsa5876 fmcsa. The need for preferential loading must be certified by a physician on a medical preferential load program attending physicianhospitalclinic form faxed directly to the terminal. Obtain a commercial drivers license learners permit.
This period is from december 22, 2015, until april 20, 2016. New dot medical certification forms mcsa dot physical doctors. Complete this form to apply for a medical doctor plate. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer. Department of transportation federal motor carrier. These are to see if the person has any conditions that could prevent him or her from driving. Includes instructions to physician and commercial drivers minimum requirements for a cdl license. Send this form and a complete copy of your most current medical examination report the dot medical card is not sufficient to. Submit only the medical doctor or osteopathic physician evaluation. The mer will be completed online at the center and does not need to be printed and completed beforehand. Application for intrastate medical waivers to operate. In preparation for an upcoming dot exam, drivers and employers should pay particular attention to the. Application for registration hold by a member of the military pdf 117. As you may or may not know, all cdl drivers and anyone who operates vehicles that require a hoisting license must possess a dot medical card.
Download fmcsa dot physical medical forms and state department of motor vehicles self. Nov 26, 2018 about the medical examination report mer form, mcsa5875. The dot 649 f form does not require any additional documents. Fax this selfcertification along with your medical examiners certificate to. Department of transport medical assessment certificate. Release of information form 49 cfr part 40 drug and alcohol testing suggested format dot agency specific documents. Cdl drivers dot medical exam form 649f pdf1 updated 1162015. Medical applications and forms federal motor carrier safety. In preparation for an upcoming dot exam, drivers and employers should pay particular attention to the conditions below that may exclude drivers from certification or require intermittent medical monitoring. Application for intrastate medical waivers to operate class a, b, or c commercial motor vehicles registry of motor vehicles medical affairs p. Medical examiners name address return to medical examiners office for follow up on telephone number if. Dot medical guidelines outline the health criteria that commercial vehicle drivers must meet to qualify for certification.
This webpage contains information and instructions to become compliant with these regulations. Medical examination report of driver under article 19a. Medical applications and forms medical examinations. Dec 18, 2019 medical applications and forms medical examinations.
Texas commercial driver license selfcertification affidavit. Medical consent form 5 documents dot physical form 2 documents bsa medical form 3 documents medical application form 4 documents generic authorization medical release form 8. Please read the detailed medical assessment instructions m106a for the applicant and health professional. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. Medical examination report mer form, mcsa5875 this form is an example of what patients can expect. Condition chapter 71 school bus driver medical regulations. Welcome to the forms resource page for the division of driver licensing.
New cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876. The cdl selfcertification authorization form and the medical examiners certificate, if applicable, must be submitted to the ohio bureau of motor vehicles and processed prior to the issuance of the cdl. Dot physical medical forms are forms for those who need to take part in the medical exam of the dot physicals. Cdl dot medical department of revenue motor vehicle. Only doctors, nurses and affiliated positions rn, pa, etc. If you need assistance with completing any of the forms below. The nyc dot parking permits and customer service call center and office at 3030 thomson avenue in long island city, queens, is closed until further notice. Applicant details to be completed by applicant or department of transport. Scdmv cdl help desk po box 1498 blythewood sc 290160028 email address. Medical certification of driver type for commercial driver. This document contains statebystate tnstructions for submitting medical certificates for cdl drivers to the state licensing agencies. The department of transportation dot medical examination is very highly regulated as illness complications can have serious consequences for the. Application for intrastate medical waivers to operate class a. Dot physical forms and others to fill out before your visit.
Adobe reader is required for all pdf files and microsoft excel and word or open office for all excel and word documents. After december 12, 2015, mcs150 and opseries forms can only be used to update company records or apply for additional authorities, not for initial registration with fmcsa. To find an approved medical examiner, you can either go to the national registry of certified medical examiner search, or call fmcsa at 202 3664001 and ask to speak to a representative. For your convenience please find below a list of forms for printing out and submitting either at your appointment or by faxing them in advance of your appointment to. Report by a prescribed person in compliance with subsection 2031 or 2032 of the. Medical examiners certificate mec, form mcsa5876 this form is an example of what certified drivers can expect.
Please complete the medical release opinion form letter below, and fax to the requesting dot certified medical examiner, or give a copy to the requesting driver patient. Certification dates are found next to each medical examiner on the national registry. Dot medical guidelines diabetes same day dot physicals. Medical examination report form for commercial driver medical certification u. New jersey medical examination form medical examination form to be completed by a licensed medical doctor or osteopathic physician. The selfcertification authorization form and the medical examiners certificate can be submitted by mail, fax, email, or a deputy registrar. Doctors of tewantin form downloads for your convenience please find below a list of forms for printing out and submitting either at your appointment or by faxing them in advance of your appointment to. Medical examiners signature temporarily disqualified due to condition or medication. Mar 09, 2018 the department of transportation dot medical examination is very highly regulated as illness complications can have serious consequences for the driver, the examiner, and the general public.
Includes cdl nrcme medical card certificate on page 9. Please do not mail or drop off applications to this location. The fmcsa announced a 120day grace period during which medical examiners may use either the current or the newly revised versions of the medical examination report mer form and medical examiners certificate mec. New york state department of transportation coordinates operation of transportation facilities and services including highway, bridges, railroad, mass transit, port, waterway and aviation facilities. For the medical certification process to be complete, this form must be submitted to the division. Medical examination report mer form, mcsa5875 fmcsa. For your convenience, many dmv pdf forms can be filled in online and then printed. Wisconsin dmv official government site medical exam report. The complete standards and instructions for conducting this examination are found in section 6. Pass a dot physical examination and provide the bmv with an valid medical examination report mer and medical examiners certificate mec. Commercial drivers are required to certify using penndots selfcertification form pdf.
What is a dot medical exam it is an exam that indicates an individual is physically qualified to operate a commercial motor vehicle in accordance with 49 cfr 391. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Medical examination report for commercial driver fitness. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a. This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f. Certain conditions have always led to shorter card terms or disqualification.
If your intrastate medical waiver has expired, see intrastate medical waiver. Commercial driver license intrastate medical waiver. Medical examiners certificate for commercial driver medical certification u. Documents and forms us department of transportation. Includes instructions to physician, minimum requirements and physical qualifications for commercial drivers. Medical certification of driver type for commercial. Pass a skills test in a vehicle class you intend to operate.
As part of the motor carrier safety improvement act, the federal motor carrier safety administration fmcsa amended the federal motor carrier safety regulations fmcsrs to require commercial drivers license cdl holders, subject to the physical qualification requirements of the fmcsrs, to provide a current copy of their medical examiners. Cdl drivers dot physical exam form 5875 pdf medical card. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. Email wisconsin dmv email service phone 608 2662327 fax 608 2670518. Medical assessment certificate fitness to drive form m107a. The exam must be current within the past 90 days, unless otherwise stated and. Please complete the medical release opinion form letter. If you are required to maintain a dot medical certificate, be sure to send a copy of that and any variance you may have along with the selfcertification affidavit. About the medical examiners certificate mec, form mcsa5876.
Dot medical examination formscertificate download dot. Cdl dot medical what is a dot medical exam it is an exam that indicates an individual is physically qualified to operate a commercial motor vehicle in accordance with 49 cfr 391. Driver licensing docking state office building attn. Depending upon the selfcertification you may also need to present a valid dot medical certificate. The links below provide access to both electronic and printonly versions of the forms. Driver id verified by has your usdot fmcsa medical certificate ever been denied or issued for less than 2 years. A copy of the results of a recent dot medical examination performed pursuant to 49 cfr 391.
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