Medical Affairs Forms and Publications

Form	Description	Instructions
Application for Disabled Parking Placard/Plate	Special Placards and Plates are available for vehicles that transport medically disabled drivers and passengers.	The Application for Disabled Placard / Plate is a two page form. You are required to complete the first page of the form only. The second page of the form is to be completed by a Massachusetts licensed physician, chiropractor or nurse practitioner. After you complete the required information, take both pages of the form to your physician, chiropractor or nurse practitioner.
Application for Intrastate Medical Waivers To Operate Class A,B, Or C Commercial Motor Vehicles	This form is used to request a medical waiver to operate Class A, B, or C Commercial Motor Vehicles.	A copy of the results of a recent DOT medical examination performed pursuant to 49 CFR 391.43, upon which the examining physician has indicated that you are only qualified to operate a commercial motor vehicle with an intrastate medical waiver. Your employment driving record for the previous five years. Your current employer's letter(s) of recommendation, including a certification that you will be engaged only in intrastate commerce within the Commonwealth of Massachusetts.
Medical Evaluation Form	This form is to be completed by your physician when the Registry has a question concerning your medical/physical qualification for driving. Additionally, this form may be used to regain your driving privilege after the voluntary surrender of your license. PLEASE NOTE: If your license is in revoked or suspended status, then your doctor may need to review documentation concerning your license status prior to this form being accepted. If your license is revoked or suspended, then please consult with a hearing officer or Driver Control staff prior to having this form completed.	Print your full name and License or Social Security number in the appropriate space. Please sign and date the form. Have your physician complete the questions concerning your medical history.
Request for Medical Evaluation	When there is a concern about a person's functional ability to operate a motor vehicle safely then it may be reported to the RMV. A valid report from anyone other than Law Enforcement or a licensed physician will trigger the need for a medical evaluation from a physician within 30 days. Information obtained directly from law enforcement or a physician is acted upon immediately.	Complete the form with as much information as possible about the person and concern as possible. We need to be able to identify the person in question within our data. All forms must be signed and dated. If completed by law enforcement, then your department's name, telephone number and supervising officer's signature are required. If completed by a physician, then your Mass. Board of Registration number is required.
Vision Screening Certificate	This form is used in lieu of the RMV eye exam and must be signed by an optometrist or physician.	Have your eye care provider complete and sign this form in the appropriate sections. Bring the completed Vision Screening Certificate with you when you come in to apply for or to renew your license.
Your Health and Driving Safely	The Registry of Motor Vehicles' guide for physicians and other medical professionals concerning medical qualification for driver licensing.	N/A

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