Physician's Statement of Examination Form
This file is a Physician's Statement of Examination required by the Michigan Department of State. It must be completed by both the driver/applicant and their physician to assess safe driving ability. Ensure all sections are filled accurately for proper evaluation.
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How do I fill this out?
Start by completing Sections 1 through 4 with relevant details about yourself. Then, have your physician fill out Sections 5 through 7 based on a recent examination. Finally, return the form to the Department of State promptly for processing.
How to fill out the Physician's Statement of Examination Form?
1
Complete Sections 1 through 4 yourself.
2
Have your physician complete Sections 5 through 7.
3
Ensure all information is accurate and legible.
4
Submit the completed form within three months.
5
Return it via fax, mail, or email.
Who needs the Physician's Statement of Examination Form?
1
Individuals who have experienced a loss of consciousness and need to report it.
2
Physicians who need to certify a patient's ability to drive safely.
3
Department of State personnel who require documentation for driver assessments.
4
Drivers applying for a medical review regarding driving capabilities.
5
Caregivers responsible for assisting individuals with driving safety evaluations.
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What are the instructions for submitting this form?
To submit this form, you can fax it to 517-335-2189 or mail it to the Michigan Department of State at P.O. Box 30810, Lansing, Michigan 48909-9832. Alternatively, you may email the completed document to MedicalForms@Michigan.gov. Ensure that the form is submitted within three months of the physician's signature to avoid any delays.
What are the important dates for this form in 2024 and 2025?
It's important to note that any form not submitted within three months of the physician's certification may result in a need for reevaluation. Be mindful of your medical examination date to avoid delays. Regularly check for updates from the Michigan Department of State regarding form requirements.
What is the purpose of this form?
The purpose of this form is to assess whether individuals have any medical conditions that could affect their ability to drive safely. It requires information from both the driver and their physician regarding health history and current medical conditions. This evaluation process helps ensure public safety on the roads.
Tell me about this form and its components and fields line-by-line.
- 1. Driver/Applicant Information: Contains personal details such as name, date of birth, and contact information.
- 2. Medical History: Includes questions about various health conditions and medications.
- 3. General Questions: Focuses on driving experience, accidents, and overall mental and physical health.
- 4. Physician's Evaluation: Requires physician's assessment of the driver's ability to operate a vehicle.
What happens if I fail to submit this form?
Failure to submit this form can lead to delays in evaluating your driving eligibility. It may result in being unable to renew your driver's license or face penalties from the Department of State. Additionally, unresolved medical issues could pose risks to safe driving.
- Potential License Suspension: Not submitting may result in losing your driving privileges.
- Increased Medical Review Needs: Lack of submission might lead to more rigorous health evaluations.
- Legal Consequences: Failure to comply can result in legal action from state authorities.
How do I know when to use this form?
- 1. Medical Evaluations: To assess if health conditions affect driving.
- 2. License Renewal: Required for renewing a license with medical implications.
- 3. Reporting Health Issues: To formally document health-related driving concerns.
Frequently Asked Question
How do I start filling out the form?
Begin by entering your personal information in Sections 1 to 4.
Can I edit this PDF file?
Yes, you can easily edit the PDF using our editor.
What should I do after completing the form?
You can submit it via fax, mail, or email as specified.
Is there a deadline to submit this form?
Yes, the form must be submitted within three months of completion.
How can I share this PDF with someone?
You can use the sharing features to send the document via email.
Do I have to print the form?
Printing is not necessary; you can fill it out digitally.
Can my physician fill out the form online?
Yes, physicians can complete the form within the provided fields.
What if I make a mistake while filling it out?
You can easily edit the form to correct any mistakes before submission.
How do I access the PDF editor?
Simply open the PDF on PrintFriendly to access the editing tools.
Will my changes be saved?
Yes, ensure to download the document after editing to keep your changes.
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