Get Med 3 Form

MEDICAL REVIEW REQUEST MED 3 05/10/2013 Purpose Use this form to request the Department of Motor Vehicles DMV to conduct a medical review of a licensed driver. Instructions Print or type all information* Complete form in its entirety. Mail completed form to Medical Review Services at the above address or fax to Medical Review Services at 1-804-367-1604. DRIVER INFORMATION GENDER DRIVER NAME last first middle MALE DMV CUSTOMER NUMBER VEHICLE PLATE NUMBER BIRTHDATE mm/dd/yyyy FEMALE TELEPHONE NUMBER If you change either your residence/home address or mailing address to a non-Virginia address your driver s license or photo identification ID card may be canceled* RESIDENCE/HOME ADDRESS CITY STATE ZIP CODE MAILING ADDRESS if different from above address REQUESTER INFORMATION Based on my observation I believe the driver named above should be given the following tests Medical Examination Vision Examination Knowledge Examination I understand that the Department of Motor Vehicles may have additional requirements. Road Skills Test Describe in detail the circumstances that led to this request. Please provide as much information as possible including a description of what appears to be the driver s mental physical or visual impairment. Use an additional sheet if necessary. REQUESTER NAME print REQUESTER BADGE NUMBER ORGANIZATION/LAW ENFORCEMENT AGENCY NAME FAX NUMBER BUSINESS STREET ADDRESS REQUESTER SIGNATURE DATE mm/dd/yyyy CONTACT INFORMATION/NOTICE If you have questions contact Medical Review Services at Virginia Code 46. 2-322 provides that if the driver submits a written request 1-804-367-6203 Voice 1-800-272-9268 Deaf or Hearing Impaired Only 1-804-367-1604 Fax DMV will furnish the reasons for the examination including the identity of anyone who supplied information regarding fitness to drive a motor vehicle. However this law states that the DMV cannot provide the information if the source is a relative or licensed medical professional treating the driver. Instructions Print or type all information* Complete form in its entirety. Mail completed form to Medical Review Services at the above address or fax to Medical Review Services at 1-804-367-1604. DRIVER INFORMATION GENDER DRIVER NAME last first middle MALE DMV CUSTOMER NUMBER VEHICLE PLATE NUMBER BIRTHDATE mm/dd/yyyy FEMALE TELEPHONE NUMBER If you change either your residence/home address or mailing address to a non-Virginia address your driver s license or photo identification ID card may be canceled* RESIDENCE/HOME ADDRESS CITY STATE ZIP CODE MAILING ADDRESS if different from above address REQUESTER INFORMATION Based on my observation I believe the driver named above should be given the following tests Medical Examination Vision Examination Knowledge Examination I understand that the Department of Motor Vehicles may have additional requirements. DRIVER INFORMATION GENDER DRIVER NAME last first middle MALE DMV CUSTOMER NUMBER VEHICLE PLATE NUMBER BIRTHDATE mm/dd/yyyy FEMALE TELEPHONE NUMBER If you change either your residence/home address or mailing address to a non-Virginia address your driver s license or photo identification ID card may be canceled* RESIDENCE/HOME ADDRESS CITY STATE ZIP CODE MAILING ADDRESS if different from above address REQUESTER INFORMATION Based on my observation I believe the driver named above should be given the following tests Medical Examination Vision Examination Knowledge Examination I understand that the Department of Motor Vehicles may have additional requirements. Road Skills Test Describe in detail the circumstances that led to this request. Please provide as much information as possible including a description of what appears to be the driver s mental physical or visual impairment.