Form Dr 500 066 PDF Details

Navigating the complexities of maintaining a Commercial Driver License (CDL) can be daunting, especially for drivers facing medical or vision challenges that fall short of the federal standards. Enter the DR 500 066 form, a beacon of hope for those in the state of Washington. This form serves as an application for the Intrastate Medical Waiver, enabling drivers with certain medical conditions the chance to legally operate commercial vehicles within the state's borders. It's a crucial document for CDL holders or applicants who find themselves in this predicament, ensuring that their livelihoods are not disrupted due to health issues. The process outlined by the form is meticulous, requiring applicants to submit a detailed Medical Examination Report alongside the application, to the Medical Unit of the Driver Records Department of Licensing. It emphasizes the importance of providing a complete and truthful account of one’s medical condition, with the stark reminder that any falsification might lead to the revocation of driving privileges. Moreover, the form opens a doorway for medical professionals, offering specific sections for doctors of various specialties to certify the applicant's medical fitness for commercial driving. This certification is not a mere formality; it's a testament to the driver's capability to safely navigate commercial vehicles, underlining the form's role in bridging the gap between regulatory standards and individual capabilities.

QuestionAnswer
Form NameForm Dr 500 066
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesimpairments, physiatrist, osteopathy, foregoing

Form Preview Example

Commercial Driver License

Intrastate Medical Waiver Application

Use this form to apply for an intrastate medical waiver if you have or are applying for a commercial driver license (CDL) and do not meet the minimum federal medical/vision standards. This form is not for drivers that do not have a CDL. Send this form and a complete copy (the DOT medical card is not sufficient) of your most current Medical Examination Report to:

Medical Unit, Driver Records

Department of Licensing

PO Box 9030

Olympia, WA 98507-9030

Fax: (360) 570-7893

Allow 7-10 business days for processing. Incomplete applications will not be processed.

PRINT or TYPE Driver name (Last, First, Middle initial)

Driver license number

Date of birth

(Area code) Telephone number

Describe the disqualifying medical condition(s) for this waiver

Certification

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

I understand that false statements on this application may result in cancellation of my commercial driving privilege.

X

Signature

Date

Physician use only–This section must be completed by a licensed medical doctor (MD), a doctor of osteopathy (DO), a board certified physiatrist (doctor of physical medicine), or an orthopedic surgeon. An optometrist or an ophthalmologist signature is acceptable for vision impairments and a certified nurse practitioner can sign only for monocular vision, color blindness, or hearing impairments.

PRINT or TYPE Medical examiner name and title

Office street address

City

 

State

ZIP code

 

 

 

 

(Area code) Telephone number

Professional license number

 

 

 

 

 

Certification

The above driver’s medical condition is not likely to interfere with the ability to safely operate a commercial motor vehicle

and is likely to remain stable for:

the next two years

other

Not more than two years

X

Medical examiner signature

Date

 

 

Title

 

DR-500-066 (R/1/12)WA

We are committed to providing equal access to our services. If you need accommodation, please call (360) 902-3900 or TTY (360) 664-0116.

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Stage # 1 of completing osteopathy

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