New York State Department of Motor Vehicles DS-6 (12/10) PHYSICIAN’S REPORTING FORM INSTRUCTIONS: Please provide all of the information requested in Parts 1 through 3 below, and sign and date the form. This form is provided for use by a physician to report an individual whose driving ability may be affected due to some physical or mental impairment. This form must be completed and signed by a licensed physician or nurse practitioner. Attach a sheet of your stationery (showing your letterhead), or a voided or blank prescription form, as additional verification for this statement, and mail the completed form with the attached stationery or prescription to: Medical Review Unit, New York State Department of Motor Vehicles, 6 Empire State Plaza, Room 220, Albany, NY 12228. If additional assistance is needed, please contact the Medical Review Unit at (518) 474-0774, option #3. Hours are 8:30 am to 12:00 pm. If your patient is an older driver, you may also visit the Resources for the Older Driver website at www.dmv.ny.gov/olderdriver. PART 1 - DRIVER IDENTIFICATION (please print) Last Name* First Name* M.I. Date of Birth (if not known, give approximate age) Street Address City* State Make of Vehicle the Person Normally Drives Color of Vehicle Zip Code License Plate Number * Required information PART 2 - DESCRIPTION OF THE DRIVER’S CONDITION Have you treated this patient? If Yes: YES NO Date of Last Examination? _______________________. Please describe the condition that you have treated or are currently treating: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Is the patient receiving medication for this condition? YES NO If Yes: Please specify the type and dosage: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ In my medical opinion, (please check one): the patient’s condition may affect the safe operation of a motor vehicle, and the patient should be evaluated by the Department of Motor Vehicles the patient’s condition prevents the safe operation of a motor vehicle and driving privileges should be suspended. Please provide further detail in the space provided or in an attached statement on your letterhead: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ PART 3 - IDENTIFICATION AND CERTIFICATION OF THE PHYSICIAN MAKING THIS REPORT Certificate or Lic. No. Your name (Print name in full) Specialty (Please specify) State Where Licensed Your Mailing Address (Include Street & No.) City State Zip Code (Area Code) & Telephone Number ( Your Signature (Sign name in full) ± ) Date (Month/Day/Year) / / American LegalNet, Inc. www.FormsWorkFlow.com