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Drivers and clinicians provide personal and diagnostic information, including clinician comments, functional ability profile (FAP) levels, oxygen saturation details, seizure or alteration-of-consciousness notes, medication reliability, and reported side effects. The form includes certification by a licensed clinician, exam date requirements, and driver authorization for release of medical information to the Secretary of State.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/driver-medical-evaluation-dr-24-rev-050123/309784/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/driver-medical-evaluation-dr-24-rev-050123/309784.png","ImageObject",300,407,{"name":92,"@type":93},"Arica Lee","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-20",true,{"@type":102,"interactionType":103,"userInteractionCount":39},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What information is this Driver Medical Evaluation form used to provide?","Question",{"text":112,"@type":113},"It provides information to the Secretary of State about a possible physical, emotional, or mental condition that could affect the driver’s ability to safely operate a motor vehicle.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What should clinicians complete in the diagnosis section?",{"text":117,"@type":113},"Clinicians must complete the diagnosis section by indicating appropriate FAP profile levels, including required notes for certain conditions and episode dates when applicable.",{"name":119,"@type":110,"acceptedAnswer":120},"How does the form handle medication and side-effect reporting?",{"text":121,"@type":113},"It records current prescribed medications and the patient’s reliability in taking them, and asks whether any side effects from current medication interfere with safe vehicle operation, with a description if yes.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},309784,1790231683,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":39,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24},8796096645457,"https://ap-avatar.wpscdn.com/avatar/800003749518d68ffe3?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345340919836971","State of Maine  \nBureau of Motor Vehicles  \nDRIVER MEDICAL EVALUATION  \nTHIS SECTION TO BE COMPLETED BY DRIVER (Please print)  \nFOR QUESTIONS call (207)624-9000, ext. 52124  \nName   Date of Birth    \nAddress   License/History Number    \n   Telephone    \nINFORMATION BELOW TO BE COMPLETED BY APPROPRIATE MEDICAL OR PARAMEDICAL PROFESSIONAL  \n1. Reason for Report: To provide information to the Secretary of State regarding a possible physical, emotional or mental condition which could affect the driver’s ability to safely operate a motor vehicle. Your report will be advisory and used to assist in determining eligibility for a driver’s license.  \n2. A Clinician Acting In Good Faith Is Immune from damages claimed as a result of filing a Driver Medical Evaluation pursuant to 29-A MRSA Section 1258 (6) . The driver’s signature is not required to submit this form.  \n3. Please Refer To Functional Ability Profiles (FAP) to assist you in completing this form. The rules are available at, [http://www.maine.gov/sos/bmv/licenses/medical.html](http://www.maine.gov/sos/bmv/licenses/medical.html. Please)[. Please](http://www.maine.gov/sos/bmv/licenses/medical.html. Please) provide Profile Level(s) for specified condition(s) or any other condition that may affect the driver’s ability to safely operate a motor vehicle.  \n4. If You Have Any Questions please call the Bureau of Motor Vehicles, Medical Section, at (207)624-9000, ext. 52124, or access the website; [http://www.maine.gov/sos/bmv/licenses/medical.html](http://www.maine.gov/sos/bmv/licenses/medical.html)  \nDIAGNOSIS  \nTHIS SECTION MUST BE COMPLETED – PLEASE PRINT OR TYPE  \n\n|  |\n| --- |\n|  |\n\nFAP PROFILE LEVEL  \nCHECK ONE BOX PER DIAGNOSIS 1 2 3A 3B  \nNOTE: For any Alteration/Loss of Consciousness, Seizure, Stroke, or Hypoglycemia episode requiring 3rd party intervention, please give date(s) and describe most recent episode(s)  For Chronic Respiratory Disease, please provide oxygen saturation and indicate if measured while using oxygen or not.  \nO2 Saturation   On room air  On oxygen For Hypoglycemia profile level 3b, please check appropriate sub-category.  3b. i.  3b. ii.  \nFor Prescription Medications and/or Opioid Replacement Therapy and patient meets criteria for profile level 3c, please check appropriate profile level sub-category.  3c. i.  3c. ii.  \nFor Substance Abuse profile level 3b, please document how long the patient has been substance free.    \nCLINICIAN COMMENTS  \n(Please document if you are recommending restrictions, road test, or suspension of license, and describe deficits or impairments with potential to affect safe driving. Attach additional documentation if needed.)  \nPlease proceed to next page…  \nMD-FR-24 (CR-24) Rev 05/01/23  \nMEDICATIONS currently prescribed: (may attach med list)  \nReliability in taking medications  \nGood Fair Poor Unknown No medication prescribed  \nHas patient reported or demonstrated any side effects from current medication(s) which would interfere with safe  \noperation of a motor vehicle? NO YES, please describe   \nCERTIFICATE OF EXAMINATION (May be submitted without the patient signature)  \nBeing duly licensed to practice in the state of   I hereby certify that I have examined this applicant.  \n(Clinician’s signature) (Degree & Specialty)  \n(Clinician’s name printed or typed) (Address)  \n(Office phone number) (Office fax number)  \nPROVIDE DATE OF LAST ASSESSMENT (Signature Date)(Must be within past 12 months or as specified by BMV)  \nReply to: Bureau of Motor Vehicles, Medical Section  \n29 State House Station  \nAugusta, Maine 04333-0029  \nTelephone: (207)624-9000 ext. 52124  \n[E-mail: medical.bmv@maine.gov](E-mail: medical.bmv@maine.gov)  \n[Fax:](Fax:) ([207](207)) 624-9319  \nFor assistance or to get a copy of the Functional Ability Profile rules, please go to:  \n[http://www.maine.gov/sos/bmv/licenses/medical.html](http://www.maine.gov/sos/bmv/licenses/medical.html or)[ or](http://www.maine.gov/sos/bmv/licenses/medical.html or)  \n[Call the Medic","cbCaip2pbcd6Z4Ve","https://ap.wps.com/l/cbCaip2pbcd6Z4Ve","pdf",403399,"English","# Reason for Report\n# Clinician Liability and Form Guidance\n# Diagnosis and FAP Profile Levels\n# Clinician Comments\n# Medications and Side Effects\n# Certificate of Examination and Exam Date\n# Driver Authorization for Release of Medical Information","[{\"question\":\"What information is this Driver Medical Evaluation form used to provide?\",\"answer\":\"It provides information to the Secretary of State about a possible physical, emotional, or mental condition that could affect the driver’s ability to safely operate a motor vehicle.\"},{\"question\":\"What should clinicians complete in the diagnosis section?\",\"answer\":\"Clinicians must complete the diagnosis section by indicating appropriate FAP profile levels, including required notes for certain conditions and episode dates when applicable.\"},{\"question\":\"How does the form handle medication and side-effect reporting?\",\"answer\":\"It records current prescribed medications and the patient’s reliability in taking them, and asks whether any side effects from current medication interfere with safe vehicle operation, with a description if yes.\"}]","DRIVER MEDICAL EVALUATION - DR - 24 - Rev 05/01/23 | PDF",1789874600]