Get Functional Ability Evaluation Medical Report

The Functional Ability Evaluation Medical Report is a crucial document for individuals applying for or renewing their driving privileges. This guide provides step-by-step instructions to help users complete the form accurately and efficiently online.

Follow the steps to fill out the form correctly and efficiently.

1. Click the 'Get Form' button to obtain the form and open it in your preferred online editor.
2. Begin by filling in your personal information in the top portion of the form. This includes your last name, first name, middle or maiden name, date of birth, and your driver license or driving privilege card number.
3. Next, provide your residential address, including street address, city, state, and zip code. Additionally, enter your Social Security Number or Individual Taxpayer Identification Number (ITIN).
4. If your mailing address differs from your residential address, fill out the mailing address section accordingly. If you have changed either address, check the appropriate box and record the new address above.
5. In the health information section, report any medical conditions that may affect your ability to drive. Be specific about conditions such as heart issues, substance use, psychiatric conditions, and any medications you are currently taking.
6. Authorize your healthcare professional to disclose relevant health information about your physical, mental, and emotional condition by signing in the designated area. Ensure you date this section as well.
7. The healthcare professional will then complete their report. They should check the appropriate functional ability profile levels for various health categories such as diabetes, cardiovascular, neurological, etc.
8. Your healthcare professional must also provide their name, degree, state license number, and contact information, ensuring that their comments are included in the designated section.
9. Finally, review all entries for accuracy, make any necessary edits, and ensure that both you and the healthcare professional have signed the form. You can now save changes, download, print, or share the completed form as required.

Complete your Functional Ability Evaluation Medical Report online today.