At the intersection of healthcare and vehicular safety lies the DS-6 form, a critical document that underscores the responsibility of medical professionals in the evaluation of individuals' fitness to drive. Originating from the New York State Department of Motor Vehicles, the Physician's Reporting Form serves a pivotal role in maintaining road safety by ensuring those behind the wheel are physically and mentally capable. This form, detailed for completion by licensed physicians or nurse practitioners, mandates a thorough account of a patient's medical condition, including the effect of any treatment or medication on their driving abilities. With parts dedicated to the identification of the driver, descriptive analysis of their condition, and the professional certification of the physician, the DS-6 embodies a structured approach to bridging healthcare findings with the operational safety protocols governing vehicle operation. Completing and signing this form, accompanied by verifiable professional stationery or prescription forms, constitutes a formal report to the State's Medical Review Unit, thus activating a process critical for the evaluation—and potentially the restriction—of driving privileges based on medical grounds. The form's existence not only underscores the legal obligations of healthcare providers but also highlights the collaborative framework aimed at safeguarding public safety on the roads.
| Question | Answer |
|---|---|
| Form Name | Dmv Form Ds 6 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ds6 ds6 form |
NewYorkStateDepartmentofMotorVehicles |
PHYSICIAN’S REPORTING FORM
INSTRUCTIONS:
PleaseprovidealloftheinformationrequestedinParts 1 through 3below,andsignanddatetheform.
Thisformisprovidedforusebyaphysiciantoreportanindividualwhosedrivingabilitymaybeaffectedduetosomephysicalormental impairment.
Thisformmustbecompletedandsignedbyalicensedphysicianornursepractitioner.
Attachasheetofyourstationery(showingyourletterhead),oravoidedorblankprescriptionform,asadditionalverificationforthis statement,andmailthecompletedformwiththeattachedstationeryorprescriptionto:MedicalReviewUnit,NewYorkState DepartmentofMotorVehicles,6EmpireStatePlaza,Room337,Albany,NY12228.
PART 1 - DRIVER IDENTIFICATION (please print)
Last |
First |
M.I. |
DateofBirth(ifnotknown, |
||
Name* |
Name* |
|
giveapproximateage) |
|
|
|
|
|
|
|
|
Street |
|
|
|
|
|
Address |
|
|
|
|
|
|
|
|
|
|
|
City* |
|
|
|
State |
Zip Code |
|
|
|
|
|
|
Make of Vehicle the Person |
Color of |
|
|
License Plate |
|
Normally Drives |
Vehicle |
|
|
Number |
|
|
|
|
|
|
|
* Required information |
|
|
|
|
|
PART 2 - DESCRIPTION OF THE DRIVER’S CONDITION
Haveyoutreatedthispatient? o YES o NO
IFYES: DateofLastExamination?_______________________.
Pleasedescribetheconditionthatyouhavetreatedorarecurrentlytreating:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Isthepatientreceivingmedicationforthiscondition? o YES o NO
IFYES: Pleasespecifythetypeanddosage:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Inmymedicalopinion,(pleasecheckone):
o thepatient’sconditionmayaffectthesafeoperationofamotorvehicle,andthepatientshouldbeevaluatedbytheDepartmentof MotorVehicles
o thepatient’sconditionpreventsthesafeoperationofamotorvehicleanddrivingprivilegesshouldbesuspended.
Pleaseprovidefurtherdetailinthespaceprovidedorinanattachedstatementonyourletterhead:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
PART 3 - IDENTIFICATION AND CERTIFICATION OF THE PHYSICIAN MAKING THIS REPORT
Your name |
|
|
Certificate or Lic. No. |
|
Specialty (Please specify) |
|
||
(Print name in full) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Your Mailing Address |
|
|
|
|
|
State Where Licensed |
||
(Include Street & No.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City |
|
State |
Zip Code |
(Area Code) & Telephone Number |
|
|||
|
|
|
|
( |
) |
|
|
|
|
|
|
|
|
|
|
|
|
Your Signature |
|
|
|
|
|
Date (Month/Day/Year) |
||
ç |
|
|
|
|
|
|
|
|
(Sign name in full) |
|
|
|
|
/ |
/ |
||