Fillable DC-119(09-19) INSTRUCTIONS TO DRIVER: Complete Section A and (State of Maryland)

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DC-119(09-19) INSTRUCTIONS TO DRIVER: Complete Section A and (State of Maryland)

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DC-119(09-19)
INSTRUCTIONS TO DRIVER: Complete Section A and have your Physician/Medical Provider complete Section B. The medical
provider should return this form to the MVA.
(Please note: Payment for any examination and preparation of this form is your responsibility.)
SECTION A – TO BE COMPLETED BY DRIVER (Print or type)
Driver License Number
Today’s Date
Last Name First Middle
Date of Birth
Address
SECTION B – TO BE COMPLETED BY MEDICAL PROVIDER
INSTRUCTIONS TO MEDICAL PROVIDER: The MVA Driver Wellness and Safety Division has been made aware that the individual
noted above may have a medical condition that
could affect their ability to safely drive. Please complete the remainder of this
report and return to:
Motor Vehicle Administration, Division of Driver Wellness and Safety, Room 124, 6601 Ritchie Highway, NE,
Glen Burnie, MD 21062, Fax 410-582-4936, Email DWSMED@mdot.maryland.gov
Note to Medical Provider:
HISTORY
DIAGNOSIS OR DISORDER (Please check all that apply)
Date of Incident/Diagnosis
Diabetes with hypoglycemic event or DKA within the past year ................................
Complications: Diabetic retinopathy Peripheral
neuropathy Most recent A1c
Lapse of consciousness, syncope, or blackouts ...........................................................
Seizure or Epilepsy ......................................................................................................
Cardiovascular condition associated with syncope ........................................................
Treatment includes: Pacemaker AICD
Stroke or other cerebrovascular disease ....................................................................
Residual impairment: No Yes, describe:
Sleep disorder, including sleep apnea or narcolepsy ..................................................
Treatment Compliant with treatment No Yes
Vision deficiency with acuity worse than 20/70 or FOV worse than 110 degrees ……
Condition affects: Right eye Left eye Both
eyes Condition is:
Stable Progressive
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
For more information visit our website at www.mva.maryland.gov,
call 410-768-7513 or TTY for the hearing impaired:
1-800-492-4575.
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_______________________
Name: Driver’s License Number:
HISTORY Continued
Date of Incident/Diagnosis
Traumatic brain injury within the past 2 years ...............................................................
Residual impairment: No Yes, describe
Dementia or cognitive impairment ................................................................................
Schizophrenia or mental health condition that may affect ability to safely drive .........
Poor decision making Hallucinations/delusions Impaired judgement Unstable emotional behavior
Neuromuscular disorder causing weakness, shaking or numbness of extremities .......
Uses assistive device for: Ambulation Driving
Loss of impairment of a hand, arm, foot or leg .............................................................
If yes, describe
Alcohol or drug dependency ..........................................................................................
If yes, what drug(s)
Has the individual participated in alcohol/drug treatment program? ☐Yes ☐No
Use of narcotic or habit-forming drugs .......................................................................
If yes, list
1. This individual is compliant with their treatment plan for the conditions noted above? Yes No (please
comment)
2. The conditions noted above are stable. Yes No (please comment)
3. Do any of the conditions noted above affect this individual’s ability to safely operate a motor vehicle?
Yes (please comment) No Not Sure (please comment)
Comments/Pertinent Diagnostic Studies:
CURRENT DIAGNOSES AND MEDICATIONS
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Medical Provider Report, Page 2 of 3
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Name: Driver’s License Number:
FITNESS TO DRIVE SUMMARY
1. Do you have concern about this individual’s ability to safely operate a motor vehicle?
Yes (please comment) No Unsure (please comment)
2. Do you think additional assessment would help to determine the medical fitness to drive, such as Drive Test,
Occupational Therapy Evaluation, Specialist Consultation, etc.?
Yes (please comment) No Unsure (please comment)
Comments:
MEDICAL PROVIDER ATTESTATION
1. How long has this individual been under your care?
2. What was the date of their last visit?
Name of Medical Provider
Specialty
Address
Phone Number Fax Number
License State/Number
Medical Provider’s Signature Date
Medical Provider Report, Page 3 of 3
DC-119 (05/2019)
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DC-119(09-19) INSTRUCTIONS TO DRIVER: Complete Section A and (State of Maryland)

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Completed 30 June 2021

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