Fillable RMV - MAB108 Loss of Consciousness Evaluation Form

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RMV - MAB108 Loss of Consciousness Evaluation Form

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Loss of Consciousness Evaluation Form
Medical Affairs ● P.O. Box 55889, Boston, MA 02205-5889
Fax: 857-368-0018
p.1 M
AB108_0118
I hereby authorize the physician 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 medical doctor who is licensed to practice in the Commonwealth of
Massachusetts.
A. Patient Information
(Please either print clearly or type)
Last Name
First Name
Middle Name
Suffix
Driver’s License #
Date of Birth (MM/DD/YYYY)
Reported Condition
The patient named above has been reported to the Registry as having experienced a “seizure, syncope, or any other type
or episode of altered consciousness which may interfere with the safe operation of a motor vehicle.” Individuals who have
experienced these episodes are required to voluntarily surrender their licenses for a period of six months. The Registry
may shorten or expand the surrender period, as an individual case may require and as indicated by the physician’s
recommendations. However, in order to shorten the Commonwealth's six-month policy for Loss of or Altered
Consciousness, the physician must ask to waive the policy with explicit reason(s) and provide all information required by
this form.
1. Please state the exact date of the most recent episode: __________________________
2. Please state cause of the epis
ode (type of disorder suffered)
______________________________________________________________________________________________
3. Please state the means, if any, by which the condition is controlled, including any medication and dosages
______________________________________________________________________________________________
4. Please state the degree of disability suffered during an episode, including the extent of the episode:
______________________________________________________________________________________________
5. Please state, in your professional opinion and to a reasonable degree of medical certainty, the probability of
reoccurrence of the episode and specific reasons for your estimate (include frequency of occurrence of the
epi
sode(s))
______________________________________________________________________________________________
Patient Name: ____________________________________________________ Last 4 Social: _________________
p.2 MAB108_0118
6. Please check one of the following categories.
I hereby certify that in my professional opinion and to a reasonable degree of medical certainty:
The patient named above is medically qualified to operate a motor vehicle safely.
Do you feel that the patient should undergo a competency road examination prior
to regaining his/her driver’s license? ......................................................................................................
Yes
No
At this time, I am unable to determine the patient’s medical qualification to operate a motor vehicle safely and
recommend that their license remain in surrendered status. I recommend that the Registry re-evaluat
e the patient’s
license eligibility on _______________________(month/year).
The patient name above is NOT medically qualified to operate a motor vehicle safely.
7. I have read the Commonwealth’s Loss of Consciousness Policy Statement referred to
above and ask to waive the six-month loss of license requirement.
........................................................ Yes No
S
ee
https://www.mass.gov/service-details/medical-standards-for-passenger-class-d-and-motorcycle-class-m-drivers-licenses
8. If applicable, please check one: I have read the attached police report and am aware of
the reported incident involving my patient. ....................................................................................
Yes
No
N/A
9. Additional Comments
B. Physician Certification
Physician’s Name
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.
Certifying Physician’s Signature: __________________________________________ Date: ___________________
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RMV - MAB108 Loss of Consciousness Evaluation Form

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Completed 22 May 2020

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