Ignition Interlock Medical Evaluation Form
This form is used by doctors to evaluate a patient's ability to use an ignition interlock device. It includes diagnosis details, medication information, and pulmonary function test results. It must be completed by a physician and mailed to the Bureau of Motorist Compliance.
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How do I fill this out?
To fill out this form, ensure all personal and medical details are accurately provided. A board-certified specialist must complete the evaluation sections. Submit the filled form to the mentioned address.
How to fill out the Ignition Interlock Medical Evaluation Form?
1
Complete the patient's personal information at the top.
2
Have a board-certified doctor fill out the medical evaluation sections.
3
Attach a copy of the pulmonary function test if applicable.
4
Ensure the doctor signs and provides their contact details.
5
Mail the completed form to the Bureau of Motorist Compliance.
Who needs the Ignition Interlock Medical Evaluation Form?
1
Patients required to use an ignition interlock device but have a medical condition.
2
Doctors evaluating patients for ignition interlock device usage.
3
Motorists with respiratory conditions that may affect their ability to use the device.
4
Healthcare professionals specializing in pulmonary medicine.
5
State motor vehicle agencies processing ignition interlock exemptions.
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What are the instructions for submitting this form?
To submit this form, mail it to the Bureau of Motorist Compliance, Medical Review Section, MS 86, Neil Kirkman Building, Tallahassee, Florida 32399-0570. Ensure all sections are completed, and that the form is signed by a board-certified physician. Attach any required documents such as recent pulmonary function test results. Submitting this form accurately and promptly is crucial for compliance with ignition interlock requirements.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form before the ignition interlock device installation date in 2024 or 2025.
What is the purpose of this form?
The purpose of this form is to provide a medical evaluation for patients required to use an ignition interlock device due to legal requirements. It assists in determining if the patient has any medical condition that impairs their ability to use the device. The form also allows for potential adjustments or exemptions based on the patient's health condition.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The full name of the patient.
- 2. DOB: The date of birth of the patient.
- 3. Date: The date the form is being completed.
- 4. Driver License#: The driver's license number of the patient.
- 5. Telephone #: The contact telephone number of the patient.
- 6. Diagnosis: Current medical diagnosis impacting the patient's ability to use the IID.
- 7. Medications: List of current medications the patient is taking.
- 8. Pulmonary function test: A copy of a recent pulmonary function test to be attached.
- 9. Physician's signature: Signature of the evaluating physician.
- 10. Physician's contact details: Contact information of the evaluating physician including address and phone number.
What happens if I fail to submit this form?
Failing to submit this form may result in non-compliance with legal requirements for ignition interlock device usage.
- Legal Consequences: Non-compliance may lead to fines or further legal action.
- Driving Restrictions: The patient may be restricted from driving until the form is submitted and approved.
How do I know when to use this form?
- 1. Medical Evaluation: When a patient's condition affects their ability to use the IID.
- 2. Legal Compliance: To comply with legal requirements for ignition interlock installation.
- 3. Waiver Request: To request a waiver or adjustment to the IID settings based on medical advice.
Frequently Asked Question
What is the purpose of this form?
This form evaluates a patient's ability to use an ignition interlock device.
Who must complete this form?
It must be completed by a board-certified pulmonologist or relevant specialist.
How can I fill out the form?
Use PrintFriendly's PDF editor to complete and save the form.
Can I attach additional documents?
Yes, you can attach a copy of the pulmonary function test and other relevant documents.
How do I sign the form?
Use PrintFriendly's signature tool to sign the form digitally.
How do I submit the form?
Mail the completed form to the Bureau of Motorist Compliance at the provided address.
Can I share the form electronically?
Yes, PrintFriendly allows you to share the form via email or a sharable link.
What should I do if I need to edit the form?
You can make edits directly on PrintFriendly before saving and downloading.
Who needs this form?
Patients with medical conditions affecting their use of an ignition interlock device, and their evaluating doctors.
What happens if I don't submit the form?
Failure to submit the form may result in non-compliance with ignition interlock requirements.
