Form P 142N – Fill Out and Use This PDF

Form P 142N is an essential document for filing taxes and other compliance initiatives. Accurately completing it can help businesses and organizations in a variety of industries maintain legal and regulatory standards, ensuring their ongoing operational processes run effectively and within the confines of necessary regulations. By properly filling out the form, entities can report information to governmental agencies accurately and promptly, ultimately allowing businesses to successfully adhere to government protocols. This helps promote structured, organized operations and financial reporting across all levels.

Form P 142N PDF Details

In order to ensure that all California employers are in compliance with state law, the Employment Development Department (EDD) has released a new form - Form P 142N. This form must be used by all employers when filing the quarterly wage and tax report, also known as Form DE 541. The release of this new form comes as a result of recent updates to the State Wage Orders, which went into effect on January 1, 2016. failure to use this new form may result in penalties from the EDD. Employers should consult the EDD website for more information on how to properly fill out and file Form P 142N.

Question	Answer
Form Name	Form P 142N
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ct neurology medical report, eversource medform ct, eversource medical forms, medical form for eversource

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NEUROLOGY MEDICAL REPORT	STATE OF CONNECTICUT
P-142N REV. 8-17	STATE OF CONNECTICUT
P-142N REV. 8-17	DEPARTMENT OF MOTOR VEHICLES
	DEPARTMENT OF MOTOR VEHICLES
	DRIVER SERVICES DIVISION
	ct.gov/dmv
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		Address incident of
operate a motor vehicle safely. This medical report must reflect the results of the licensed physician's		Address incident of

personal examination of the patient performed within 90 days of this report being filed. It must be signed by
the patient authorizing the physician to release this report and any attachments to DMV.

DRIVER'S LICENSE NUMBER

CDL/PS YES NO

I hereby authorize the licensed physician completing and signing this medical report to release such report to DMV along with any other medical information necessary to determine my fitness to operate a motor vehicle safely.

PATIENT'S NAME (Please Print)

(Last)

(First)

PATIENT'S SIGNATURE

(Initial)	DATE OF BIRTH

DATE

TELEPHONE NUMBER

()

PATIENT'S ADDRESS

(Street)

(City)

(State)

(Zip Code)

HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?

DATE OF LAST EXAMINATION

HOW MANY YEARS HAS THIS PATIENT HAD THE CONDITION(S) YOU ARE TREATING? PLEASE PROVIDE A BRIEF DIAGNOSIS, ETIOLOGY, AND PROGNOSIS, INCLUDING DATES AND RESULTS OF EEG SCANS, AND/OR OTHER TEST RESULTS, AS NEEDED.

ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST? PLEASE EXPLAIN:

HISTORY OF EPISODES OF ALTERED CONSCIOUSNESS IN THE PAST TWO YEARS

DATE

TYPE	DATE	TYPE	DATE	TYPE
			5.
	3.		5.
	4.		6.

MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)

DATE OF LAB WORK TYPE/DOSE

BLOOD LEVEL

DATE OF LAB WORK

TYPE/DOSE

BLOOD LEVEL

DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT

PERIODIC REPORTING?	YES	NO	IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
	YES	NO
	CONDITION		EVERY	MONTHS FOR	YEAR(S)

	CONDITION		EVERY	MONTHS FOR	YEAR(S)

DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S) WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?

DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?

DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS (INCLUDING ILLICIT DRUGS)?

ARE YOU AWARE OF ANY OTHER RELEVANT MEDICAL OR SURGICAL HISTORY? PLEASE EXPLAIN:

CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?

YES NO

NOT APPLICABLE

PHYSICIAN'S 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.

PHYSICIAN'S NAME (Please print or type)

OFFICE ADDRESS (Include Zip Code)

TELEPHONE NUMBER

()

PHYSICIAN'S SIGNATURE

PHYSICIAN'S LICENSE NUMBER

PHYSICIAN'S SPECIALTY

DATE REPORT COMPLETED

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Form P 142N – Fill Out and Use This PDF

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