Fill - Free fillable MAB118 - Psychiatric Evaluation Form

Psychiatric Evaluation Form

Registry of Motor Vehicles ● Medical Affairs

P.O. Box 55889 ● Boston, MA 02205-5889

FAX: 857-368-0018 ● PHONE: 857-368-8020

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I hereby authorize the person completing this form to discuss and release any or all medical records pertaining to its

content with or to representatives of the Registry of Motor Vehicles.

Applicant’s Signature: __________________________________________________ Date: ________________________

This form must be fully completed by a physician: a medical doctor who is licensed to practice in the

Commonwealth of Massachusetts or a psychiatric nurse practitioner.

A. Patient Information

Last Name

First Name

Middle Name

Suffix

Date of Birth (MM/DD/YYYY)

License #

Reported Condition

The Registry of Motor Vehicles has received information that the patient named above may have a condition which could

affect his/her ability to operate a motor vehicle. Please complete the following so that the RMV can fairly evaluate the

impact of your patient’s condition upon his/her ability to operate a motor vehicle safely:

1. Please describe the patient’s psychiatric condition, using DSM-V or ICD-10 diagnosis:

2. Please describe the extent, frequency, and control of the symptoms of the patient’s condition or disability which may

affect his/ her ability to operate a motor vehicle (i.e., oriented in all spheres, dissociative episodes, etc.):

3. Is

the patient’s psychiatric condition or disability likely to interfere with his/her mental or physical

ability to operate a motor vehicle safely? ...................................................................................................  Yes  No

4. If condition involves seiz

ure or any type of altered or loss of consciousness, please state type and date of last episode:

5. Is patient on any medication(s)?  Yes  No If Yes, please list medication(s) with dosage(s):

6. Are these medications, separately or in combination, likely to interfere with his/her ability to operate

a motor vehicle safely? ..............................................................................................................................  Yes  No

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6. Please check one of the following categories:

I hereby certify that in my professional opinion and to a reasonable degree of medical certainty, one of the following:

 The patient named above is medically qualified to operate a motor vehicle safely.

 The patient named above is NOT medically qualified to operate a motor vehicle safely.

 I am unable to determine driving ability and recommend the patient undergo a competency road examination.

7. Please check one:

I have read the attached police report and am aware of the reported incident

involving my patient. ....................................................................................................................  Yes  No  N/A

8. Additional Comments:

B. Physician Certification

Physician’s /RN’s Name Phone #

Massachusetts Board of

Registration #

Address

Street

City

State

Zip Code

I hereby certify, under the pains and penalties of perjury, that the information I have provided herein is true and

correct.

Signature: _____________________________________________________________ Date: _____________________

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Fillable MAB118 - Psychiatric Evaluation Form - Fillable

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