Dmv Form P 40 PDF Details

In Connecticut, the DMV P-40 form plays a crucial role in evaluating individuals' fitness to operate motor vehicles safely. This Initial Medical Request form, issued by the Department of Motor Vehicles' Driver Services Division, requires a thorough medical assessment by a licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN) who has examined the patient within the last 90 days. Comprehensive in nature, the form covers a wide range of medical conditions that may impair driving abilities, including but not limited to alcohol/substance abuse, Alzheimer's/Dementia, various cardiovascular conditions, neurological disorders, and psychiatric or emotional disturbances. Medical professionals must detail the patient's health status, indicating whether any diagnosed condition could compromise their ability to drive. Furthermore, the form solicits the healthcare provider's opinion on whether the individual should undergo a road test or needs special equipment to drive safely. Importantly, it also includes a section for patient authorization, allowing the release of their medical information to the DMV or the Bureau of Rehabilitative Services (BRS), thereby adhering to the regulatory prerequisites for confidentiality and consent. This document is not only a measure of one's physical and mental capability to drive but also a crucial step in ensuring public safety on the roads of Connecticut.

QuestionAnswer
Form NameDmv Form P 40
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdmv cdl forms, p40 medical form online, ct dmv cdl forms, ct cdl medical forms

Form Preview Example

INITIAL MEDICAL REQUEST

STATE OF CONNECTICUT

P-40 REV. 8-2017

DEPARTMENT OF MOTOR VEHICLES

 

DRIVER SERVICES DIVISION

 

ct.gov/dmv

Address incident of

DRIVER'S LICENSE NUMBER

CDL/PS YES NO

MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013

The patient named below has been referred to the DMV Driver Services Division concerning their ability to safely operate a motor vehicle. This medical report must reflect the results of the medical professional's (licensed physician, PA or APRN) personal examination of the patient performed within 90 days of this report being filed. It must be signed by the patient authorizing the medical professional to release this report and any attachments to DMV.

I hereby authorize the medical professional completing and signing this medical report to release such report to DMV and/or Bureau of Rehabilitative Services (BRS) along with any other medical information necessary to determine my fitness to safely operate a motor vehicle.

PATIENT'S SIGNATURE

DATE

X

PATIENT'S NAME (Please Print)

(Last)

(First)

(Initial)

DATE OF BIRTH

TELEPHONE NUMBER

()

PATIENT'S ADDRESS (Street)

(City)

(State)

(Zip Code)

Indicate to the best of your knowledge any and all condition(s) pertaining to this patient.

Alcohol/Substance Abuse

Alzheimer's/Dementia

Cardiovascular/Hypertension

Cerebral Palsy

Cystic Fibrosis

Endocrine/Glandular

Liver/Renal Failure

Narcolepsy

Neurological/Neuromuscular

Ophthalmologic

Orthopedic

Peripheral Vascular Disease

Psychiatric/Emotional Disorder

Pulmonary/Sleep Apnea

Other

HOW LONG HAVE YOU BEEN TREATING THIS PERSON AND FOR WHAT CONDITION(S)?

CONDITION:

TREATMENT BEGAN:

DATE OF LAST EXAMINATION

IF TREATED BY ANOTHER PHYSICIAN, PLEASE INDICATE NAME, ADDRESS AND SPECIALTY OF PHYSICIAN.

PHYSICIAN'S NAME (Please Print or Type)

OFFICE ADDRESS (Include Zip Code)

PHYSICIAN'S SPECIALTY

This individual has NO medical matters which would affect his/her ability to safely operate a motor vehicle.

I do not have sufficient information to determine this person's ability to operate a motor vehicle.

Considering this patient’s condition(s), do you believe this person should be road tested and/or evaluated for special equipment requirements?

YES

NO

MEDICAL PROFESSIONAL CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion of this report. I swear or affirm under penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to penalties for perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.

MEDICAL PROFESSIONAL'S NAME (Please Print or Type)

OFFICE ADDRESS (Include Zip Code)

TELEPHONE NUMBER

MEDICAL PROFESSIONAL'S LICENSE NUMBER

MEDICAL PROFESSIONAL'S SPECIALTY

()

MEDICAL PROFESSIONAL'S SIGNATURE

DATE REPORT COMPLETED

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connecticut p40 writing process detailed (portion 1)

2. Your next step is usually to fill out these particular fields: Cystic Fibrosis, EndocrineGlandular, LiverRenal Failure, Narcolepsy, PsychiatricEmotional Disorder, PulmonarySleep Apnea, Other, HOW LONG HAVE YOU BEEN TREATING, CONDITION, TREATMENT BEGAN, DATE OF LAST EXAMINATION, IF TREATED BY ANOTHER PHYSICIAN, PHYSICIANS NAME Please Print or, OFFICE ADDRESS Include Zip Code, and PHYSICIANS SPECIALTY.

connecticut p40 writing process explained (step 2)

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3. In this specific part, take a look at I do not have sufficient, Considering this patients, YES, MEDICAL PROFESSIONAL CERTIFICATION, MEDICAL PROFESSIONALS NAME Please, OFFICE ADDRESS Include Zip Code, TELEPHONE NUMBER, MEDICAL PROFESSIONALS LICENSE, MEDICAL PROFESSIONALS SPECIALTY, MEDICAL PROFESSIONALS SIGNATURE, and DATE REPORT COMPLETED. Each of these have to be filled out with highest accuracy.

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