Form DS-6 - Physician's Request for Driver Review - New York - Edit, Fill, Sign Online

Have you treated this patient? o YES o NO

If Yes: Date of Last Examination? _______________________.

Please describe the condition that you have treated or are currently treating:

________________________________________________________________________________________________

Is the patient receiving medication for this condition? o YES o NO

If Yes: Please specify the type and dosage:

__________________________________________________________________________________________________________

In my medical opinion, (please check one):

o the patient’s condition may affect the safe operation of a motor vehicle, and the patient should be evaluated by the Department of

Motor Vehicles

o the patient’s condition prevents the safe operation of a motor vehicle and driving privileges should be suspended.

Please provide further detail in the space provided or in an attached statement on your letterhead:

__________________________________________________________________________________________________________

PHYSICIAN’S REPORTING FORM

INSTRUCTIONS:

l Please provide all of the information requested in Parts 1 through 3 below, and sign and date the form.

l This form is provided for use by a physician, physician assistant, or nurse practitioner to report an individual whose driving ability may be

affected due to some physical or mental impairment.

l This form must be completed and signed by a licensed physician, physician assistant or nurse practitioner.

l Attach a sheet of your stationery (showing your letterhead), or a voided or blank prescription form, as additional verification for this

statement, and mail the completed form with the attached stationery or prescription to: Medical Review Unit, New York State

Department of Motor Vehicles, 6 Empire State Plaza, Room 337, Albany, NY 12228.

l If additional assistance is needed, please contact the Medical Review Unit at (518) 474-0774, option #3. Hours are 8:30 am to 12:00 pm.

l If your patient is an older driver, you may also visit the Resources for the Older Driver website at www.dmv.ny.gov/olderdriver.

PART 1 - DRIVER IDENTIFICATION (please print)

PART 2 - DESCRIPTION OF THE DRIVER’S CONDITION

Last

Name*

Street

Address

City* State

Driver License

Number

Zip Code

First

Name*

M.I. Date of Birth (if not known,

give approximate age)

DS-6 (5/15)

* Required information

Your name

(Print name in full)

Your Mailing Address

(Include Street & No.)

Your Signature

(Sign name in full)

City

Date (Month/Day/Year)

/ /

State Zip Code

(Area Code) & Telephone Number

( )

Certificate or Lic. No.

State Where Licensed

ç

Specialty (Please specify)

PART 3 - IDENTIFICATION AND CERTIFICATION OF THE PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER

COMPLETING THIS REPORT

Please Note: Based on the medical information submitted, our reviewer may ask for further medical details, or may request additional

information from a pertinent sub-specialist, ex: cardiologist; neurologist

Fillable Printable Form DS-6 - Physician's Request for Driver Review - New York

Fillable Printable Form DS-6 - Physician's Request for Driver Review - New York

Form DS-6 - Physician's Request for Driver Review - New York