Dds 1207 Form PDF Details

Dds 1207 form is a document that is used to submit the medical reimbursement claim for an individual. The form can be used by both healthcare providers and patients. The submission of this form allows for the patient to receive compensation for the services provided. The use of this form is required in order to process a medical reimbursement claim. The Dds 1207 form is a document that is used to submit the medical reimbursement claim for an individual. This document can be used by both healthcare providers and patients, in order to allow the patient to receive compensation for services provided. In order to process a medical reimbursement claim, using this form is mandatory. When submitting this form, it's important ensure all information included is accurate.

This basic report can help you figure out the time it'll take you to fill out dds 1207 form, the number of pages it has, and a handful of other specific specifics of the form.

QuestionAnswer
Form NameDds 1207 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesself certification, commercial self certification form, form 1207, dds 1207 form

Form Preview Example

 

 

 

 

 

THIS FORM IS ACCEPTED IN-PERSON AT A CSC ONLY.

 

 

 

 

 

COMMERCIAL DRIVER SELF-CERTIFICATION FORM

 

 

 

 

 

 

 

 

DRIVER LICENSE NUMBER

 

 

 

 

 

DATE OF BIRTH (MM/DD/YYYY)

 

 

 

 

 

 

 

 

APPLICANTS NAME (Last, First, MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE, ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AREA CODE/ TELEPHONE NUMBER

 

 

EMAIL ADDRESS:

HOME (

)______________________________

OTHER (

)______________________________

 

 

 

 

 

 

 

 

 

 

 

 

FMCSA CERTIFICATIONS (INITIAL BESIDE APPLICABLE STATEMENT) - See Self-Certification Guidelines

Self-Certification

 

A.

Non-Excepted Interstate - I certify that I will operate or expect to operate in interstate or foreign commerce, that I am subject

Categories A-D

 

 

 

 

 

 

 

to and meet the FMCSA driver qualification requirements under 49 CFR part 391, and I am required to obtain a medical

(Initial Only One)

 

 

 

 

 

 

 

 

examiner’s certificate. I also certify that I do not have an impairment of an arm, foot, or leg that interferes with the normal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

tasks associated with the operation of a CMV. (Medical Certificate needed)

A, B – Medical Certificate

B.

Non-Excepted Intrastate - I certify that I will operate entirely in intra state commerce only and that I meet the FMCSA driver

 

 

 

 

 

 

qualification requirements as defined in 49 CFR 391. I also certify that I do not have an impairment of an arm, foot, or leg

needed.

 

 

 

 

 

 

 

 

 

 

that interferes with the normal tasks associated with the operation of a CMV.(Medical Certificate needed)

 

 

 

 

 

 

 

 

 

 

 

 

 

C, D – Medical

 

 

C.

Excepted Interstate - I certify that I will operate or expect to operate in interstate commerce, but engage exclusively in

 

 

 

 

 

transportation or operations excepted under 49 CFR §§390.3(f), 391.2, 391.68 or 398.3 from all or parts of the qualification

Certificate NOT

 

 

 

 

 

 

 

 

 

 

requirements of 49 CFR part 391, and I am therefore not required to obtain a medical examiner’s certificate. (Medical

needed.

 

 

 

 

 

 

 

 

 

 

Certificate not needed)

 

 

 

 

 

 

 

 

 

 

 

D.

Excepted Intrastate - I certify that I will operate in city, county, state, or federal vehicle only, and I am exempt from the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FMCSA driver qualification requirements of 49 CFR 390.3(f). (Medical Certificate not needed)

 

 

 

 

 

 

 

 

Licenses, Disqualifications,

 

 

 

I certify that I am not subject to any disqualification defined in 49 CFR §383.51or any license suspension, revocation, or

and Withdrawals

 

 

 

 

 

 

 

 

cancellation pursuant to the laws of any State.

Initial, if Transfer From

 

 

 

 

 

 

I certify that I do not have a driver’s license from more than one State or jurisdiction.

Another State or First

 

 

 

 

 

 

 

 

 

Issuance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUIRED ACKNOWLEDGEMENT AND SIGNATURES (INITIAL BESIDE ALL STATEMENTS)

 

 

 

Under penalty of law, I swear or affirm that I am a resident of the State of Georgia or that I qualify for a Nonresident CDL, and the information provided on

 

 

 

this application is true and correct. I understand that it is illegal to make false, fictitious, or fraudulent statements on this application. I grant permission

 

 

 

to the Department of Driver Services (DDS) to verify information furnished to the Department through the release of any and all applicant information to

 

 

 

third parties which shall include,

but not be limited to the U.S. Department of Homeland Security, the Federal Motor Carrier Safety Administration or other

 

 

 

public or private entities wherein such disclosure of the information by the Department is not prohibited by law.

 

 

 

I understand that the DDS will check my driving record through available national databases, including, but not limited to, the Commercial Driver License

 

 

 

Information System (CDLIS), for the purpose of determining my eligibility for issuance of the requested licenses or permits.

 

 

 

Print Name

 

 

 

 

Date

 

 

 

Applicant’s Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Document Type:

 

When Must I Update It?

Mail To:

Fax To:

 

Online At:

In-Person:

 

 

 

 

DDS

(770)918-6271

 

www.dds.ga.gov

At your nearest DDS

 

 

 

 

Attn: RM-CDL

 

 

 

 

 

Individual customers

Create an online account

Customer Service Center

 

 

 

 

P.O. Box 80447

 

 

 

 

 

 

 

 

 

Conyers, GA 30013

only

to upload documents.

 

 

 

 

 

Individual and multiple

 

 

 

 

Visit www.dds.ga.gov to

 

 

 

 

 

 

 

 

find the center nearest

 

 

 

 

customer submissions

 

 

 

 

 

 

 

 

 

 

 

 

you.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self-Certification

 

Update ONLY if you

 

 

 

 

 

 

 

 

 

have a change in driving

NO

NO

 

NO

YES

 

 

 

status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Valid Medical

 

Prior to the document’s

 

 

 

 

 

 

 

Certificate and/or

 

expiration date

YES

YES

 

YES

YES

 

Medical Variance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have any additional questions regarding this matter please feel free to contact the DDS’ Customer Contact Center at (678) 413-8400.

DDS-1207 (11/15)

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