Form DS 326 at a glance
What it is: Form DS 326 is the Driver Medical Evaluation: the DMV records indicate the patient may have a condition that could affect the safe operation of a motor vehicle.
Who signs: Before giving this form to your medical professional, complete and sign Sections 1-3. Sections 5-13 are to be completed by a physician, physician's assistant or advanced practice registered nurse.
A filled-in Form DS 326 example: a driver completes Sections 1-3
How to fill out Form DS 326, box by box
Return by, fax number and physician return form to
In this case, the department is concerned about a condition, and the form also prints RETURN BY, FAX NUMBER and PHYSICIAN RETURN FORM TO.
Section 1 - Driver Information
In Section 1, Driver Information, enter the name (last, first, middle), the driver license number, the birth date, the street address, the city, the ZIP and the patient's daytime or home phone number.
Driver must complete health history
The driver must complete the health history and explain any “YES” answers.
In the explanation, include the onset date, diagnosis, medication, doctor's name and address and any current condition or limitation, and attach an additional sheet, if needed.
Driver's certification and signature
Certify (or declare) under penalty of perjury under the laws of the State of California that all information concerning your health is true and correct.
Under DATE and DRIVER'S SIGNATURE, enter the date and sign.
Section 3 - Medical Information Authorization
In Section 3, Medical Information Authorization, enter the name and address of the medical professional, hospital, or medical facility, the date and the medical record or patient file number.
You authorize your medical professional or hospital to answer any questions from the DMV, or its employees, relating to your physical or mental condition, and/or drug and/or alcohol use, and to release any related information or records to the DMV or its employees. Any expense involved is to be charged to you and not to the DMV.
You authorize the DMV to receive any information relating to your physical or mental condition, and/or drug and/or alcohol use or abuse, and to use the same in determining whether you have the ability to operate a motor vehicle safely.
Under SIGNED and DATE, sign and enter the date.
Section 5 - Vision
In Section 5, Vision, enter the visual acuity (without bioptic telescope) for both eyes, the right eye and the left eye, without lenses and with present lenses.
List any eye injury or disease. Mark Yes or No: is further eye examination suggested?
Section 7 - Treatment under your supervision
In Section 7, Treatment under your supervision, enter the diagnosis. If the diagnosis is a disorder characterized by lapses of consciousness, dementia, or diabetes, complete page 3, 4 or 5.
Section 9 is Dementia or Cognitive Impairments, Section 10 is Lapse of Consciousness Disorder and Section 11 is Diabetes.
Section 13 - Medical Professional's Signature
In Section 13, Medical Professional's Signature, sign at MP'S SIGNATURE and enter the MP'S name (printed), the date, the classification or specialty, the medical license number and the telephone number.
More rules for Form DS 326
Please answer all questions on this form. If questions do not apply, indicate “N/A”.
You may furnish a narrative report if you prefer, but please include all information pertinent to your patient.
All records of the DMV, relating to the physical or mental condition of any person, are confidential and not open to public inspection (CVC §1808.5). Information used in determining driving qualifications is available to you and/or your representative with your signed authorization.
The department has sole responsibility for any decision regarding your driving qualifications and licensure. The department will also consider non-medical factors in reaching a decision.
You may wish to make a copy of the completed Driver Medical Evaluation for your records.
Common questions about Form DS 326
What is a DS 326 form?
Form DS 326 is the Driver Medical Evaluation: the DMV records indicate the patient may have a condition that could affect the safe operation of a motor vehicle. Medical information is confidential under California Vehicle Code §1808.5 CVC.
Sources
[1] Driver Medical Evaluation, DS 326 (REV. 6/2020), California DMV (the Official source link on this page).
