Enlarge the copy to ensure that all information is legible. All cmv drivers are required to pass dot physicals in order to get their medical cards, and their physicals must be conducted by a certified medical examiner cme. Medical examiners are required to complete the medical examination report form for every driver physical examination performed in accordance with 49 cfr 391. Depending on how you selfcertify determines what cdl medical documents will be required. You are an interstate nonexcepted driver and must meet the federal dot medical card requirements e. All cdl drivers must selfcertify in one of four categories no later than january 30, 2014.
Medical examination report form federal motor carrier. Massachusetts department of transportation cdl selfcertification form, t21893, download the form here from massdot. If you are subject to the department of transportation dot medical card requirements, provide a copy of each new dot. The kansas division of vehicles requires all cdl holders to comply with federal motor carrier safety regulation 49 cfr section 383. Dot medical examination formscertificate download dot. Medical examiners certificate mec, form mcsa5876 fmcsa. The cdl selfcertification authorization form and the medical examiners certificate, if applicable, must be submitted to the ohio bureau of motor vehicles and processed prior to the issuance of. Drivers can also monitor their own clp cdl medical certification status through mydmv and subscribe for text andor email notifications. Read before installing fill and sign any pdf form containing acrofields. Intrastate nonexcepted you must meet the state dot medical requirements. It may take up to 10 business days for medical information to be posted from the time it is received by alea. Questions regarding the cdl medical mergerself certification forms should be submitted here.
Cdl drivers dot medical exam form certificate mcsa 5875 pdf new cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876. Dot medical card pdf pa dot medical card form dl11cd 2. Dot physical form fill out and sign printable pdf template. Dot physical form fill online, printable, fillable, blank pdffiller. Medical examination report mer form, mcsa5875 fmcsa. Fill, sign and send anytime, anywhere, from any device with pdffiller. Commercial vehiclescdl iowa department of transportation. Most frequent questions about dot medical cards cleanfleet. Medical examiners national registry verification required for dot compliance, place in driver qualification file motor carrier instructions. Kansas commercial drivers license holder medical self certification. You are an interstate excepted driver and do not have to meet the federal dot medical card requirements. This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f.
The department of transportation dot requires commercial motor vehicle cmv operators to have the dot physical exam to maintain their driver certification. Enter your full name, residential address with landmarks, and your phone numbers in first section medical information of wallet sized medical information card. Insulintreated diabetes mellitus assessment form, mcsa5870. Selfcertifying and submitting your medical certificate to ohio bmv. If you have certified to category 1, nonexcepted interstate, you are required to submit a current medical certification card and. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate mec, form mcsa5876.
The mer will be completed online at the center and does not need to be printed and completed beforehand. How to confirm that the medical certificate is on my driving record. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. Dot medical exam and commercial motor vehicle certification about the exam. Each original paper or electronic completed medical examination report form must be retained on file at the office of the medical examiner for at least 3 years from the date of.
Statebystate instructions for submitting medical certificates for cdl drivers to the state agencies. A complete medical examination report form, mcsa5875, with any attachments embodies my findings completely and correctly, and is on file in my office. Medical applications and forms medical examinations. Fill out, securely sign, print or email your dot physical forms florida instantly with signnow.
This document contains statebystate tnstructions for submitting medical certificates for cdl drivers to the state licensing agencies. You must meet the federal dot medical certificate requirements. Fmcsa form mcsa5875 us department of transportation. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration fmcsa national registry. Free walletsized medical information card pdf form download. Carrier are subject to appropriate penalty if the driver operates a motor vehicle in. Proceed to section 2, emergency contacts and provide contact information in case of emergency. I love it it helped me fill in some va medical forms and made them look very. Dot physical forms printable fill out and sign printable pdf. Part 391 of the fmcsrs state that the use of schedule 1 drugs by a driver is an automatic disqualification from operating a. Texas commercial driver license selfcertification affidavit. Examiners certificate also referred to as a medical certificate or medical card.
Dmv will send notifications regarding cdl clp downgradecancellation events to passenger carriers enrolled in the 19a system. Medical examiners telephone number date certificate signed medical examiners name please print or type md do. Dotmedical informationintrastate dps driver license. All commercial drivers are required to pass a physical exam conducted by a licensed medical examiner at least once every 24 months. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. About the insulin treated diabetes mellitus itdm assessment form, mcsa5870. Your federal medical certificate is required unless you drive a school bus or drive for a. Federal motor carrier safety regulations fmcsrs to require interstate commercial drivers license cdl holders, subject to the physical qualification requirements of the fmcsrs, to provide a current copy of their medical examiners certificate dot physical card to their state driver licensing agency. If you are required to maintain a dot medical certificate, be sure to send a.
They will give you the medical card and they will send the long form to pa so it in the system or they give you the long form and you send it or whatever pa say you need to do. Medical certificates and selfcertification how to selfcertify or change your current selfcertification status. Fill out your medical self certification form and include a copy of your dot physical card. Visit a driver licensing office location to selfcertify or to change your selfcertification status. Get, create, make and sign dot certificate form get form. Medical examination report mer form, mcsa5875 this form is an example of what patients can expect. Dot form fill online, printable, fillable, blank pdffiller. The oklahoma department of public safety dps will be adding your medical certification status and the information on your medical examiners certificate to your commercial drivers license system cdlis record. Kansas commercial drivers license holder medical self. Collection of most popular forms in a given sphere. Beginning may 21, 2014, a commercial driver who is renewing or obtaining a new medical examiners certificate must be examined by a medical professional listed on the. Attach photos, save created document, view it, mail it, share it, etc.
The carrier must retain a copy of this certificate. Yes, otherwise the commercial drivers designation will be removed downgraded to a noncommercial drivers license upon. To help you make your medical id, we have three free online sources for printing your own wallet cards updated 11418. Dot physical forms and others to fill out before your visit. Inspiring printable dot medical card printable images.
The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiner s certificate mec, form mcsa5876 to drive. As a part of the medical certification process for insulin treated diabetes mellitus itdm individuals, the federal motor carrier safety administration requires that the insulin treated diabetes mellitus assessment form itdm, mcsa5870, be completed by the itdm individuals treating. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate. Beginning may 21st, 2014, verification must be made that the medical examiner who signed a drivers medical card is. Medical examiners certificate federal motor carrier. Email add annotation share dot medical card is not the form youre looking for. Passing the cdl medical exam is a mandatory step for commercial license applicants in the united states, as drivers must prove they are physically and mentally fit to operate a commercial vehicle. Certified drivers will receive their mec after the exam is completed. Mv3001 wisconsin driver license dl application wisconsin dot. Copy of your valid dot medical card medical card only, not the long form. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Insurance is not accepted for physicals at minuteclinic. Commercial driver license selfcertification and medical examiner certificate. A dot medical card is administered by a certified medical examiner only after a driver meets the dot physical requirements.
Cdl holders that certify to the nonexcepted interstate category must provide a copy of their medical examiners certificate to the iowa department of transportation. If you are an ni or na categorized driver, you will need to recertify, using this same form, prior to each expiration of your medical certificate. Thus, if you find a disqualifying condition for which a driver may receive a federal motor carrier safety administration medical exemption, please record that on the drivers medical examiners certificate, form mcsa5876, as well as on the medical examination report form, mcsa5875. Medical examiners certificate mec, form mcsa5876 this form is an example of what certified drivers can expect. Dot medical card form printable medical alert card dot medical card sample dot medical card. Massachusetts cdl and dot medical card requirements. If a cdl holders driving privilege is currently under suspension or disqualified, do they still need to submit the selfcertification form andor medical examiners certificate dot physical card to penndot. Federal motor carrier safety administration fmcsa regulations 49 c. Without a valid dot medical card, drivers may lose their commercial drivers license. Updated 142018 if you have afib and youre taking a blood thinner or other medications, you may want to carry your medical information. State of rhode island and providence plantations division of motor vehicles commercial drivers license office 600 new london avenue cranston, ri 029203024 phone. Selfcertificationmedical examiners certification faq. According to the fmcsa, all cdl holders must undergo a dot physical by a certified medical examiner to receive a dot medical card.
1574 461 1351 1561 1225 80 517 542 940 1157 984 1049 756 1289 297 615 1595 152 1343 304 464 1565 1540 1590 24 304 653 150 14 1084 931 944 273 1566 1103 477 1112 16 357 250 1227 296 938