The DMV Med 3 form is a crucial document designed for those who see the need to request a medical review for a licensed driver, possibly due to concerns over their ability to safely operate a vehicle. This comprehensive form aims to facilitate this process by gathering detailed information about the driver in question, including their personal details and any observations related to their mental, physical, or visual capabilities that may affect their driving abilities. The form not only allows the requestor to specify the type of examinations (medical, vision, knowledge, and road skills test) they believe should be conducted but also provides space for an in-depth description of the circumstances and behaviors observed that led to the concern. To complete the MED 3, one must provide both the driver's and the requester's information, ensuring the DMV can follow up effectively. This includes names, addresses, and contact details, alongside the requester's association and signature to officially lodge the request. Once filled, the form can be mailed or faxed to the Medical Review Services, demonstrating the DMV's commitment to road safety by examining drivers whose capabilities may be in question. It's important for requestors to note that the involved driver can request the reasons for the examination, highlighting a transparent process, albeit with anonymity protected for certain informants like relatives or the driver's medical professionals.
| Question | Answer |
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| Form Name | Dmv Form Med 3 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | mailing, Impaired, impairment, furnish |
MEDICAL REVIEW REQUEST
MED 3 (05/10/2013)
Purpose: Use this form to request the Department of Motor Vehicles (DMV) to conduct a medical review of a licensed driver.
Instructions: Print or type all information. Complete form in its entirety. Mail completed form to Medical Review Services at the above address, or fax to Medical Review Services at
DRIVER INFORMATION
DRIVER NAME (last, first, middle) |
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GENDER |
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BIRTHDATE (mm/dd/yyyy) |
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MALE |
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FEMALE |
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DMV CUSTOMER NUMBER |
VEHICLE PLATE NUMBER |
TELEPHONE NUMBER |
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If you change either your residence/home address or mailing address to a
RESIDENCE/HOME ADDRESS |
CITY |
STATE |
ZIP CODE |
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MAILING ADDRESS (if different from above address) |
CITY |
STATE |
ZIP CODE |
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REQUESTER INFORMATION
Based on my observation, I believe the driver named above should be given the following tests: |
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Medical Examination |
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Vision Examination |
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Knowledge Examination |
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Road Skills Test |
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I understand that the Department of Motor Vehicles may have additional requirements. |
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Describe in detail the circumstances that led to this request. Please provide as much information as possible including a description of what appears to be the driver's mental, physical or visual impairment. Use an additional sheet if necessary.
REQUESTER NAME (print) |
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REQUESTER BADGE NUMBER |
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ORGANIZATION/LAW ENFORCEMENT AGENCY NAME |
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TELEPHONE NUMBER |
FAX NUMBER |
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BUSINESS STREET ADDRESS |
CITY |
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STATE |
ZIP CODE |
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REQUESTER SIGNATURE |
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DATE (mm/dd/yyyy) |
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CONTACT INFORMATION/NOTICE
If you have questions, contact Medical Review Services at: |
Virginia Code § |
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(Voice) |
DMV will furnish the reasons for the examination, including the identity of |
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anyone who supplied information regarding fitness to drive a motor vehicle. |
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(Deaf or Hearing Impaired Only) |
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However, this law states that the DMV cannot provide the information if the |
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(Fax) |
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source is a relative or licensed medical professional treating the driver. |
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