Driver Wellness & Safety Forms

Consent for the Release of Confidential Information (Form #DC-088) This form is used to provide the MVA with the names of all doctors, hospitals, alcohol/drugs clinics and other programs where you have received treatment.

Treatment Provider's Report(Form #DC-118) This form is to be completed by your treatment provider (hospital, alcohol or drug clinic) and is used as an aid in determining your qualifications to drive.

Physician/Health Care Provider Report (Form #DC-119) This form is to be completed by your physician/health care provider and is used as an aid in determining the qualifications of an individual to drive.

Health Questionnaire (Form #DC-001) This form is used to provide a comprehensive medical history regarding your medical status as it related to driving.

Alcohol & Drug Use Questionnaire (Form #DC-001A) This form is used to provide a detailed alcohol/drug use history.

Physician Referral (Form #DC-220) This form is to be completed by a physician/health care provider to report concerns about medical fitness to drive.


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