Fillable Printable Form DS-704 - Article 19-A Bus Driver's Diabetic Follow-Up - New York

Form DS-704 - Article 19-A Bus Driver's Diabetic Follow-Up - New York

ARTICLE 19-A BUS DRIVER’S DIABETIC FOLLOW-UP

NYS DMV COMMISSIONER’S REGULATION PART 6.10

NOTE: If insulin is necessary to control a diabetic condition, the driver is not qualified to operate a bus if the bus

driver has an established medical history or clinical diagnosis of diabetes mellitus which has not been stabilized by

insulin therapy to the degree that his or her personal healthcare provider (physician, nurse practitioner, or physician

assistant) can certify that such person has not had an incident of hyperglycemic/hypoglycemic shock for a period of

two years. Where diabetes can be stabilized by a diet or hypoglycemic agent, the driver must be under adequate

medical supervision and follow-up.

The follow-up for all drivers with diabetic conditions shall consist of certification every six months by the driver’s

personal healthcare provider that his or her condition has remained stabilized and that he or she has not had an

incident of hyperglycemic/hypoglycemic shock since the last certification.

This form may be used by a motor carrier to document the required 6-month diabetic follow-up by the driver’s

personal healthcare provider.

I, ___________________________________________________________________, am acting as the above-named

bus driver’s personal healthcare provider. He/she is under my care and treatment for an existing diabetic condition.

His/her condition is stabilized by (indicate which):

www.dmv.ny.gov

DS-704 (5/15)

(Print Personal Healthcare Provider’s Name)

(Personal Healthcare Provider must sign)

BUS DRIVER’S NAME: ________________________________________________________

DATE OF BIRTH: ________________________________________________________

DRIVER

LICENSE ID NUMBER (9- digit number on driver license): ______________________________

(Must correspond to name on driver’s license)

Date ____________________________

Professional License or Certificate Number: ______________________________________ Issuing State: ________

Address: ______________________________________________________________________________________

_____________________________________________________________________________________

Phone: ________________________

I certify that he/she has not

had an incident of hyperglycemic or hypoglycemic shock within the last six months.

Personal Healthcare Provider’s Signature: __________________________________________________________

¨ Diet

¨ Medication (identify):____________________________________________ Form of Insulin: ¨Yes ¨ No

¨ Other means (explain):______________________________________________________________________

¨ M.D. ¨ D.O ¨ PA (physician assistant) ¨ NP (nurse practitioner)

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