STATE OF CONNECTICUTHOSPITAL ER PHYSICIAN 'S IMPAIRED DRIVER REPORTDRIVER 'S LICENSE NUMBERDEPARTMENT OF MOTOR VEHICLES DRIVER SERVICES DIVISION On The Web At: ct.gov/dmvP142ER Rev. 112017CDL/PSYESNOMAIL.
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How to fill out the CT P-142ER online
This guide provides clear, step-by-step instructions for completing the CT P-142ER, a report specifically for physicians regarding impaired drivers. Whether you are familiar with legal forms or are encountering this process for the first time, this comprehensive guide will support you in accurately filling out the form online.
Follow the steps to complete the CT P-142ER accurately.
- Press the ‘Get Form’ button to access the CT P-142ER form and open it for completion.
- Enter the driver's license number of the patient in the designated field.
- Write the patient's name clearly in the spaces provided, including their last name, first name, and initial.
- Fill in the patient's address accurately to ensure proper communication.
- Provide the patient's date of birth in the specified format.
- Record the date of the examination to confirm the timeline of the assessment.
- Select the type of impairment from the provided options, indicating all that apply.
- If there are other impairments or medical conditions, please specify them in the space provided.
- Add any physician comments relevant to the report that may assist in understanding the patient's condition.
- Complete the physician's certification section by confirming that an examination was conducted within the last 90 days and that the information is true.
- Print or type your name in the physician's name section, followed by the name of the hospital.
- Include your telephone number for any follow-up communications regarding the form.
- Date the report to indicate when it was completed.
- Affix your signature to certify the report, along with your specialty and license number.
- Indicate the state of issue for your medical license.
- Once all sections are filled, ensure that you save your changes, and you may also download, print, or share the completed form as needed.
Complete your required documentation online today.
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