Kansas commercial drivers license holder medical self. Dot physical forms and others to fill out before your visit. Dot medical card pdf pa dot medical card form dl11cd 2. Dmv will send notifications regarding cdl clp downgradecancellation events to passenger carriers enrolled in the 19a system. Medical examiners national registry verification required for dot compliance, place in driver qualification file motor carrier instructions. You are an interstate excepted driver and do not have to meet the federal dot medical card requirements. Email add annotation share dot medical card is not the form youre looking for. Medical examination report mer form, mcsa5875 fmcsa. Dot medical exam and commercial motor vehicle certification about the exam.
Examiners certificate also referred to as a medical certificate or medical card. If a cdl holders driving privilege is currently under suspension or disqualified, do they still need to submit the selfcertification form andor medical examiners certificate dot physical card to penndot. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. Dot medical examination formscertificate download dot. Beginning may 21st, 2014, verification must be made that the medical examiner who signed a drivers medical card is. Mv3001 wisconsin driver license dl application wisconsin dot. Passing the cdl medical exam is a mandatory step for commercial license applicants in the united states, as drivers must prove they are physically and mentally fit to operate a commercial vehicle. Yes, otherwise the commercial drivers designation will be removed downgraded to a noncommercial drivers license upon.
A dot medical card is administered by a certified medical examiner only after a driver meets the dot physical requirements. Selfcertificationmedical examiners certification faq. Insulintreated diabetes mellitus assessment form, mcsa5870. To help you make your medical id, we have three free online sources for printing your own wallet cards updated 11418.
The oklahoma department of public safety dps will be adding your medical certification status and the information on your medical examiners certificate to your commercial drivers license system cdlis record. Medical examiners certificate mec, form mcsa5876 this form is an example of what certified drivers can expect. Medical applications and forms medical examinations. They will give you the medical card and they will send the long form to pa so it in the system or they give you the long form and you send it or whatever pa say you need to do. Most frequent questions about dot medical cards cleanfleet. Federal motor carrier safety administration fmcsa regulations 49 c.
If you are required to maintain a dot medical certificate, be sure to send a. The federal motor carrier safety administration fmcsa has learned that some medical examiners mes listed on the national registry of certified medical examiners national registry are completing the drivers medical examiners certificate mec incorrectly. Massachusetts department of transportation cdl selfcertification form, t21893, download the form here from massdot. You are an interstate nonexcepted driver and must meet the federal dot medical card requirements e. About the insulin treated diabetes mellitus itdm assessment form, mcsa5870. It may take up to 10 business days for medical information to be posted from the time it is received by alea. Medical examination report mer form, mcsa5875 this form is an example of what patients can expect. This document contains statebystate tnstructions for submitting medical certificates for cdl drivers to the state licensing agencies. Dot physical form fill online, printable, fillable, blank pdffiller.
This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f. Dot medical card form printable medical alert card dot medical card sample dot medical card. All cmv drivers are required to pass dot physicals in order to get their medical cards, and their physicals must be conducted by a certified medical examiner cme. Medical certificates and selfcertification how to selfcertify or change your current selfcertification status. Proceed to section 2, emergency contacts and provide contact information in case of emergency. Texas commercial driver license selfcertification affidavit. Carrier are subject to appropriate penalty if the driver operates a motor vehicle in. If you have certified to category 1, nonexcepted interstate, you are required to submit a current medical certification card and. Without a valid dot medical card, drivers may lose their commercial drivers license.
Dot physical forms printable fill out and sign printable pdf. Medical examiners certificate federal motor carrier. Fmcsa form mcsa5875 us department of transportation. Statebystate instructions for submitting medical certificates for cdl drivers to the state agencies. Your federal medical certificate is required unless you drive a school bus or drive for a.
Certified drivers will receive their mec after the exam is completed. To obtain and maintain a cdl you may be required to have a dot medical card. Enter your full name, residential address with landmarks, and your phone numbers in first section medical information of wallet sized medical information card. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration fmcsa national registry. Insurance is not accepted for physicals at minuteclinic. Dot form fill online, printable, fillable, blank pdffiller. The mer will be completed online at the center and does not need to be printed and completed beforehand. Visit a driver licensing office location to selfcertify or to change your selfcertification status. The cdl selfcertification authorization form and the medical examiners certificate, if applicable, must be submitted to the ohio bureau of motor vehicles and processed prior to the issuance of.
Questions regarding the cdl medical mergerself certification forms should be submitted here. Updated 142018 if you have afib and youre taking a blood thinner or other medications, you may want to carry your medical information. Dot physical form fill out and sign printable pdf template. Medical examiners telephone number date certificate signed medical examiners name please print or type md do. Medical examiners certificate mec, form mcsa5876 fmcsa. Commercial driver license selfcertification and medical examiner certificate. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate mec, form mcsa5876. The department of transportation dot requires commercial motor vehicle cmv operators to have the dot physical exam to maintain their driver certification. If you mark category 1, you must also submit a copy of your completed medical examiners certificate. All commercial drivers are required to pass a physical exam conducted by a licensed medical examiner at least once every 24 months. Enlarge the copy to ensure that all information is legible. Each original paper or electronic completed medical examination report form must be retained on file at the office of the medical examiner for at least 3 years from the date of.
Federal motor carrier safety regulations fmcsrs to require interstate commercial drivers license cdl holders, subject to the physical qualification requirements of the fmcsrs, to provide a current copy of their medical examiners certificate dot physical card to their state driver licensing agency. Get, create, make and sign dot certificate form get form. If you are subject to the department of transportation dot medical card requirements, provide a copy of each new dot. Fill out your medical self certification form and include a copy of your dot physical card. Fill, sign and send anytime, anywhere, from any device with pdffiller. Beginning may 21, 2014, a commercial driver who is renewing or obtaining a new medical examiners certificate must be examined by a medical professional listed on the. All cdl drivers must selfcertify in one of four categories no later than january 30, 2014. You must meet the federal dot medical certificate requirements. Dot physical forms cdl medical examination report mer form, mcsa5875 this form is an example of what patients can expect.
Medical examination report form federal motor carrier. Dotmedical informationintrastate dps driver license. As a part of the medical certification process for insulin treated diabetes mellitus itdm individuals, the federal motor carrier safety administration requires that the insulin treated diabetes mellitus assessment form itdm, mcsa5870, be completed by the itdm individuals treating. Commercial vehiclescdl iowa department of transportation. Intrastate nonexcepted you must meet the state dot medical requirements.
Cdl drivers dot medical exam form certificate mcsa 5875 pdf new cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876. Copy of your valid dot medical card medical card only, not the long form. Thus, if you find a disqualifying condition for which a driver may receive a federal motor carrier safety administration medical exemption, please record that on the drivers medical examiners certificate, form mcsa5876, as well as on the medical examination report form, mcsa5875. Drivers can also monitor their own clp cdl medical certification status through mydmv and subscribe for text andor email notifications. Kansas commercial drivers license holder medical self certification. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. State of rhode island and providence plantations division of motor vehicles commercial drivers license office 600 new london avenue cranston, ri 029203024 phone. Free walletsized medical information card pdf form download. Massachusetts cdl and dot medical card requirements. Selfcertifying and submitting your medical certificate to ohio bmv. According to the fmcsa, all cdl holders must undergo a dot physical by a certified medical examiner to receive a dot medical card. Read before installing fill and sign any pdf form containing acrofields. The carrier must retain a copy of this certificate. Depending on how you selfcertify determines what cdl medical documents will be required.
Collection of most popular forms in a given sphere. A complete medical examination report form, mcsa5875, with any attachments embodies my findings completely and correctly, and is on file in my office. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiner s certificate mec, form mcsa5876 to drive. The kansas division of vehicles requires all cdl holders to comply with federal motor carrier safety regulation 49 cfr section 383. Part 391 of the fmcsrs state that the use of schedule 1 drugs by a driver is an automatic disqualification from operating a. Attach photos, save created document, view it, mail it, share it, etc. I love it it helped me fill in some va medical forms and made them look very. If you are an ni or na categorized driver, you will need to recertify, using this same form, prior to each expiration of your medical certificate. Cdl holders that certify to the nonexcepted interstate category must provide a copy of their medical examiners certificate to the iowa department of transportation. Inspiring printable dot medical card printable images. Fill out, securely sign, print or email your dot physical forms florida instantly with signnow.