Request for Medical Evaluation
Medical Affairs ● P.O. Box 55889, Boston, MA 02205-5889
Fax: 857-368-0018
p.1 MAB107_0118
This form is used to report a person you believe is no longer physically or medically capable of operating a motor vehicle
safely. Please provide as much information as possible.
(Required)
Driver’s License # OR Social Security Number
Date of Birth (MM/DD/YYYY)
By signing this form, I swear (affirm), under the penalties of perjury, that the information I have provided is true and correct.
Signed: _____________________________________________________________ Date:_________________________
Name (Please print): __________________________________________________ Phone: _______________________
B. For Law Enforcement or Health Care Provider Only (If not law enforcement or a health care provide, leave blank)
Please check one of the following categories:
I hereby certify that in my professional opinion and to a reasonable degree of certainty,
The person named above in NOT medically qualified to operate a motor vehicle safely.
I am unable to determine driving ability and I recommend the person undergo a competency road examination.
The person may require adaptive equipment and/or an assessment for appropriate license restrictions via a
competency road examination.
Please complete applicable areas:
Signature: ___________________________________________________________ Date ________________________
Name (Please print): __________________________________________________ Phone: ______________________
Profession/Title (e.g. Law Enforcement or Health Care Provider)
Place of Employment (e.g. Saugus Police Dept. or Boston Medical Center)
Medical Professionals, please provide Board of Registration Number
Law Enforcement Professionals: Was the driver cited by you?
No Yes, Citation Number:
Health Care Provider Definition: A registered nurse, licensed practical nurse, physician, physician’s assistant,
psychologist, occupational therapist, optometrist, ophthalmologist, osteopath, physical therapist, or podiatrist who is a
licensed health care provider under the provisions of M.G.L., Chapter 112.
Please briefly describe reason for concern (Required):
