PS31077-15 (10/16)
INSTRUCTIONS
• Mail the completed form to:
Driver and Vehicle Services, Driver Evaluation Unit, 445 Minnesota Street, St. Paul, Minnesota 55101-5170
Or Fax to: (651) 282-2463
• If you have questions or need additional information:
please contact DVS at (651) 296-2025, (651) 282-6555 (TTY) or email: dvs.driverslicense@state.mn.us
• The requested information is needed to determine if your medical condition may interfere with your ability to safely
operate a motor vehicle. If your driving privileges are canceled based on the information provided by you or your
physician, you have the right to a review by the Diabetic Medical Review Board. Requests for a review must be
submitted in writing to Driver and Vehicle Services at the address listed above.
• Reporting requirements for drivers with insulin-treated diabetes are established in Minnesota Rules, chapter 7410.
Failure to provide complete and accurate information will result in the loss of your driving privileges.
• Additional waivers are required for commercial driving privileges.
MINNESOTA RULE 7410.2610 - INSULIN-TREATED DIABETES MELLITUS
Subp. 3.
Reporting diagnosis of insulin-treated diabetes or episode.
A person shall report a diagnosis of insulin-treated diabetes or an episode, in writing, to the department as follows:
A. after a diagnosis of insulin-treated diabetes:
(1) at the time of applying for a driver's license; and
(2) within 30 days after the diagnosis;
B. for a driving-related episode:
(1) within 30 days after the episode; and
(2) on a regularly scheduled physician's statement as required in subpart 3a; and
C. for a non-driving-related episode, on a regularly scheduled physician's statement as required in subpart 3a.
If a person has reason to know the requirements of items A and B, and willfully fails to report or willfully makes a material misrepresentation
to the department concerning the person's diabetic condition, the commissioner shall suspend the person's driver's license for six months. The
six-month suspension period will begin within 30 days from the date the department discovers the failure to report or misrepresentation.
Subp. 3a.
Physician's statement required.
A physician's statement, on a form prescribed by the commissioner, is required:
A. after the person:
(1) is diagnosed as having insulin-treated diabetes; or
(2) has a driving-related episode under subpart 3; and
B. every six months until the person has been episode free for a year; and then
C. annually until the person has been episode free for four years; and then
D. every four years; and additionally
E. as recommended by the physician or by the department.
The six-month, one-year, or four-year period will begin from the date the most recent physician's statement has been received and approved by
the department. During a period of cancellation or suspension under this part, the department shall not require a physician's statement until the
end of the cancellation or suspension period.
If a person fails to return a physician's statement to the department within 30 days from the date of mailing, the commissioner shall cancel the
person's driver's license until the physician's statement is submitted to the department and accepted.
The physician's statement must indicate, at least, the date of each of the person's episodes since the previous physician's statement, whether the
person is cooperating in the treatment of the condition, the person's prognosis for control of the person's diabetic condition, and whether the
person is medically qualified to exercise reasonable and ordinary control over a motor vehicle on the public roads.
Insulin-Treated Diabetes Mellitus Report
