Dl 124 Form PDF Details

Are you familiar with the Dl 124 form? If not, you should be. This form is used to request a hearing with Social Security Administration to dispute a denial of your social security disability benefits. Filling out this form can be tricky, so here's some advice on how to do it right. First, make sure you have all of your information gathered together. This includes medical records, work history, and contact information for people who can verify your disability. Once you have everything together, fill out the form completely and accurately. Double-check your work before submitting it, and then submit it to the SSA office closest to you. Remember, the sooner you file for a hearing, the sooner you'll get a decision from the SSA.

QuestionAnswer
Form NameDl 124 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesgeneral neurological form, dl 124 form, dot forms for neurological, neurological form template

Form Preview Example

DL-124 (12-12)

GENERAL NEUROLOGICAL FORM

PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION

Bureau of Driver Licensing P.O. Box 68682 Harrisburg, PA 17106-8682 (717) 787-9662

THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 11/16/2012

Provider: For more information relating to Medical Reporting, visit http://www.dmv.state.pa.us/centers/medicalReportingCenter.shtml.

PATIENT INFORMATION (Please complete this form in its entirety)

DRIVER’S LICENSE NO.

LAST NAME(S)

JR. ETC FIRST NAME

HEIGHT

SEX

EYE COLOR

 

DATE OF BIRTH

TELEPHONE NUMBER

E-MAIL (if applicable)

FEET

INCHES

 

 

MONTH

DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.

CITY

STATE ZIP CODE

1.How long have you been treating the patient?__________________________________________________________________________

2.Has the patient been diagnosed with a neurologic disorder? ______________________________________________________________

3.Has the patient had a loss of consciousness due to cerebral vascular insufficiency? ___________________________________________

If yes, date of last episode:__________________

4.Does the patient have impairment in any of the following areas which would make him/her unsafe to drive?

a.Reaction time? ________________________________________________________________________________________________

b.Coordination of movement of the extremities? _______________________________________________________________________

c.Muscular strength? _____________________________________________________________________________________________

5.Does the patient have any paralysis? __________ If yes, please explain: ___________________________________________________

6.Does the patient have excessive aggressiveness or disregard for the safety of self or others or both that would make him/her

unsafe to drive? _________________________________________________________________________________________________

7.Does the patient have any cognitive impairment(s) which would make him/her unsafe to drive, including but not limited to attentiveness to the task of driving, judgement and problem solving, planning and sequencing, visuospatial perception and or memory? _______________

8.Has the patient had a loss of visual fields?_____________ If yes, please explain: _____________________________________________

9.Is the patient being treated with medicine? __________ If yes, please specify: ______________________________________________

____________________________________________________________________________________________________________

Does the medication(s) make him/her an unsafe driver?

o YES o NO

HEALTH CARE PROVIDER INFORMATION (Please print or type)

HEALTH CARE PROVIDER'S NAME

SPECIALTY

 

HEALTH CARE PROVIDER’S LICENSE NUMBER

 

 

 

 

 

 

 

STREET ADDRESS

CITY

 

STATE

ZIP CODE

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsiication to authorities) punishable by a ine up to $2,500 and/or

imprisonment up to 1 year.

 

 

 

Health Care Provider's Signature

 

Date

 

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Filling out segment 1 of neurological form printable

2. The third stage would be to submit these fields: c Muscular strength, Does the patient have any, Does the patient have excessive, unsafe to drive, Does the patient have any, the task of driving judgement and, Has the patient had a loss of, Is the patient being treated with, Does the medications make himher, HEALTH CARE PROVIDER INFORMATION, HEALTH CARE PROVIDERS NAME, SPECIALTY, HEALTH CARE PROVIDERS LICENSE, STREET ADDRESS, and CITY.

The way to complete neurological form printable part 2

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3. This subsequent part is usually quite straightforward, I hereby state that the facts, Health Care Providers Signature, and Date - these fields will have to be completed here.

neurological form printable conclusion process clarified (stage 3)

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