Commercial driver license medical selfcertification form. Please submit this completed selfcertification form and your medical examiners. Cdl drivers dot physical exam form 5875 pdf medical card. Medical examiner certificate fill out and sign printable. Medical examiners certificate for commercial driver medical certification u. When entering results for examinations conducted on or after december 22, 2015, you will be presented with a revised version of the cmv driver medical examination results form, mcsa5850 attached. May 21, 2014 commercial driver license selfcertification and medical examiner certificate. Cdl drivers dot medical exam form 649f pdf 9 pages. Continue using the original paper medical examiners certificate, form. The complete standards and instructions for conducting this examination are found in section 6. The way to complete the online dot physical forms printable on the internet. Drivers conversations you should have with your doctor. 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 the cdl. The medical examiner is responsible for certifying only drivers who meet the physical qualification standards.
Medical examination report form for commercial driver medical certification u. The driver was otherwise medically qualified and given a medical examiners certificate. Complete appropriate paperwork prior to examination, including. If this information is not completed, your appointment will be rescheduled. Dec 22, 2015 cdl drivers dot medical exam form 649f pdf1 updated 1162015.
Welcome to the national registry of certified medical. The most secure digital platform to get legally binding, electronically signed. If there is a change in your medical status or interstateintrastate status you mustprovide a new selfcertification form. 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. 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 clinician attesting that the. This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Nurse will obtain height, weight, vital signs and urine sample. Medical examiner s certificate mec, form mcsa5876 this form is an example of what certified drivers can expect. Welcome to the national registry of certified medical examiners there is a new way to sign into the national registry with login. Mar 09, 2018 the department of transportation dot medical examination is very highly regulated as illness complications can have serious consequences for the driver, the examiner, and the general public. New cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876.
The dot physical examination forms medical examination report mer and medical examiners certificate mec are available from the federal motor carrier safety administration fmcsa. Insulintreated diabetes mellitus assessment form, mcsa. Sample exam questions dot medical examiner certification. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer. Department of transportation federal motor carrier safety administration. The department of transportation dot medical examination is very highly regulated as illness complications can have serious consequences for the. Dot physical form fill online, printable, fillable, blank pdffiller. Medical examiners signature temporarily disqualified due to condition or medication. Please complete the medical release opinion form letter.
Dot medical examination formscertificate download dot. Complete guide to medical examiner certification introduction the national registry of certified medical examiners hereinafter referred to as the national registry was established in accordance with the. Once your physical is complete, the medical examiner will give you a medical examiners certificate form mcsa5876. For diabetes, vision, or hearing exemptions, visit driver exemption programs.
Dot medical guidelines diabetes same day dot physicals. Insulin treated diabetes mellitus, assessment form. Medical examiners name address return to medical examiners office for follow up on telephone number if. National registry of certified medical examiners coming soon a new national registry. Fmcsa continues to develop a new national registry to better serve you. The following medical examiner has been verified as being listed on the national registry of certified medical examiners as of the date of issuance of the medical examiners certificate for the. Medical examination report mer form, mcsa5875 fmcsa. Therefore, when entering results for examinations conducted on.
About the medical examiners certificate mec, form mcsa5876. The date found on the top right corner of the medical. Guide for new jersey commercial driver license cdl. Be licensed, certified, or registered in accordance with applicable state laws and regulations to perform physical examinations. A physical examination needs to be conducted by medical examiner that has license and the examiners are the ones who have been listed in the federal motor carrier safety administration fmcsa national registry. The medical examiner s certificate wallet card is required to be carried by every driver of a commercial motor vehicle as a proof of medical qualification in 49 cfr 391. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. When you are being evaluated after a severe hypoglycemic episode, you must retain this form and give. Medical examiners certificate mec, form mcsa5876 fmcsa. Use this form to document verification and place this form in the drivers qualification file. Medical examiners certificate form mcsa 5876 notice to health care providers regarding medical examiners certificate pdf pennsylvania commercial drivers manual pdf selfcertification guide pdf. Dot physical forms printable esign pdf with electronic. Medical applications and forms medical examinations.
Safety consideraonshouldbeconsideredwhenmakingthecer. Dot medical guidelines outline the health criteria that commercial vehicle drivers must meet to qualify for certification. Medical examination report of driver under article 19a. The requirement to include verification of the medical examiners national registry. The selfcertification authorization form and the medical examiners certificate can be submitted by mail, fax, email, or a deputy registrar. National registry of certified medical examiners fmcsa. All commercial drivers are required to pass a physical exam conducted by a licensed medical examiner at least once every 24 months. Use this stepbystep instruction to fill out the dot medical form quickly and with ideal accuracy.
Certification cannot exceed 2 years, and at the discretion of the fmcsa medical examiner, may be less than 2 years. Pdf versions of the forms are available at these links on the fmcsa. Commercial driver license selfcertification and medical examiner certificate. The medical examiners certificate wallet card is required to be carried by every driver of a commercial motor vehicle as a proof of medical qualification. Fmcsa form mcsa5875 us department of transportation. Certification dates are found next to each medical examiner on the national registry. Cmv drivers seeking a medical examiners certificate as of may 21, 2014, must obtain it from a federally certified medical examiner listed on the national registry website located at. New jersey medical examination form medical examination form to be completed by a licensed medical doctor or osteopathic physician. Commercial driving operation is permitted across state lines and you. Bureau of motor vehicles cdl compliance unit 29 state house station augusta, me 043330029. Fmcsa federal exemption programs for commercial drivers. The driver was otherwise medically qualified and given a medical examiners certificate indicating that the driver must also have a federal diabetes exemption. Start a free trial now to save yourself time and money.
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a. The term is included, but it isnt limited for the doctor of osteopathy do, doctor of medicine md. Medical examination report for commercial driver fitness. Please complete the medical release opinion form letter below, and fax to the requesting dot certified medical examiner, or give a copy to the requesting driver patient.
Medical applications and forms federal motor carrier safety. Includes instructions to physician, minimum requirements and physical qualifications for commercial drivers. Welcome to the national registry of certified medical examiners. Fax this selfcertification along with your medical examiners certificate to. The medical examiner determines certification status. Medical examination report for commercial driver fitness determinationmedical examiners certificate. Health history driver completes this section, but medical examiner is. This is the correct response because it is the only option that is included on the medical examination report form for physical. About the medical examiners certificate mec, form mcsaif the medical.
Beginning may medical examiners national registry verification motor carrier instructions. Federal dot cmv medical examination requirements 2315 eighth street lewiston, id 83501 tel. 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. 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 examiner s certificate mec, form mcsa5876. Healthcare professionals wishing to become a certified medical examiner listed on the national registry are now able to register. Department of transportation dot requires the drivers to have dot medical form. Medical examiners certificates issued prior to may 21, 2014, are valid until the expiration date on the certificate. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.
Medical certification of driver type for commercial. Medical examination report mer form, mcsa5875 this form is an example of what patients can expect. A medical examiner performed the initial examination of a driver with diabetes mellitus who uses insulin. The mer will be completed online at the center and does not need to be printed and completed. 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. Apr 20, 2019 department of transportation dot requires the drivers to have dot medical form. Drivers with monocular vision may apply for an exemption. About the medical examiner s certificate mec, form mcsa5876. Pdf versions of the forms are available at these links on the fmcsa website. When you are being evaluated after a severe hypoglycemic episode, you must retain this form and give it to the certified medical examiner at your next medical certification examination. The mer will be completed online at the center and does not need to be printed and completed beforehand. A driver with a past medical history of congestive heart failure chf comes to see the medical examiner for his annual recertification examination. Insulintreated diabetes mellitus assessment form, mcsa5870.
New dot medical certification forms mcsa dot physical doctors. Includes instructions to physician, minimum requirements, physical qualifications and cdl medical certificate for commercial drivers. Dot medical examiner certification practice exam questions. Medical certification of driver type for commercial driver. The advanced tools of the editor will direct you through the editable pdf. A medical examiner, ophthalmologist, or optometrist may perform and certify vision test results. Health history driver completes this section, but medical examiner is encouraged to discuss with driver. Nov 26, 2018 the federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. During this process, you may continue to access the current national registry until our transition to the new national registry is complete. As part of the motor carrier safety improvement act, the federal motor carrier safety administration fmcsa amended the federal motor carrier safety regulations fmcsrs to require commercial drivers license cdl holders, subject to the physical qualification requirements of the fmcsrs, to provide a current copy of their medical examiners. Federal motor carrier safety administration fmcsa regulations 49 c.
Includes cdl nrcme medical card certificate on page 9. Commercial driving operation is permitted across state lines and you are required to meet federal medical requirements. Cmv drivers seeking a medical examiners certificate as of may 21. Depending on how you selfcertified or what your medical condition is, one or more of the following documents may be required. Medical examiners are required to complete the medical examination report form for every driver physical examination performed in accordance with 49 cfr 391. Fill out, securely sign, print or email your medical examiner certificate form instantly with signnow.
Dot physical forms and others to fill out before your visit. Please submit this completed selfcertification form and your medical examiner s certificate from a certified medical examiner andor medical waiver, if applicable by mail. Federal diabetes exemption application package quartelyendocrinologistevaluationform508. Discussion of medical history and exam with medical examiner. Cdl drivers dot medical exam form 649f pdf1 updated 1162015. The newly designed driver card fits any standard size wallet. Guide for new jersey commercial driver license cdl holders. Department of transportation federal motor carrier.
About the insulin treated diabetes mellitus itdm assessment form, mcsa5870. The carrier must retain a copy of this certificate. For your convenience, many dmv pdf forms can be filled in online and then printed. Massdot, rmv division, driver licensing po box 55889 boston, ma 02205 submit. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. To find an approved medical examiner, you can either go to the national registry of certified medical examiner search, or call fmcsa at 202 3664001 and ask to speak to a representative. The medical examiner s certificate wallet card is an integral part of the driver qualification file. Cmv driver medical examination results form, mcsa5850. A physical examination needs to be conducted by medical examiner that has license and the examiners. Nj mvc cdl selfcertification and medical examiner certificate.