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The form requires complete answers and physician assessment of disease or condition, treatment history, diagnoses, medications, control status, and results of relevant tests. 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The MVD makes the final decision to accept or deny the application.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"Which sections must physicians complete and answer carefully?",{"text":118,"@type":114},"Physicians must answer every section, check all applicable diseases/conditions, provide follow-up details, list significant diagnoses that could affect safe driving, include treatment details, and indicate whether the patient is capable of safe and competent driving.",{"name":120,"@type":111,"acceptedAnswer":121},"What driving recommendations are requested in the form?",{"text":122,"@type":114},"The physician must recommend any driving restrictions (e.g., daylight only, corrective lenses, mechanical/prosthetic aids) and indicate the recommended renewal interval for the next driver’s license issuance.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},310016,1790080483,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":24},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","MVD–10124  \nRev 8/23  \nNEW MEXICO TAXATION & REVENUE DEPARTMENT, MOTOR VEHICLE DIVISION  \nMEDICAL REPORT  \n| Please be advised that the decision to allow an applicant to continue to retain his/her New Mexico driver’s license is contingent upon the information provided in this medical report. It is imperative that all questions be answered completely. This form will become part of the applicant’s record; It is for confidential use of the physician or division and may not be divulged to any person or used as evidence in any trial.\u003Cbr>ALL INFORMATION MUST BE TYPED OR CLEARLY PRINTED |  |  |  | Recommend Testing |\n| --- | --- | --- | --- | --- |\n|  |  |  |  | ❑ N/A\u003Cbr>❑ Skills exam |\n| Applicant Information |  |  |  |  |\n| !pplicant’s Name (Last, First, Middle Initial) |  |  | Date of Birth |  |\n| Mailing Address |  | City, State ZIP Code |  |  |\n| Area code + Telephone Number | E-mail Address | Social Security Number | NM Driver’s License Number |  |\n| Physician’s Report |  |  |  |  |\n| 1. DISEASE or CONDITION-Note: a) Provide details in \\#5 below for any box checked.\u003Cbr>❑ Neurological ❑ Cardiovascular ❑ Diabetes ❑ Seizure\u003Cbr>❑ Psychological ❑ Dementia ❑ Hypoglycemia\u003Cbr>❑ Epilepsy ❑ Loss of Consciousness ❑ Orthopedic/Prosthetic\u003Cbr>❑ Other (please specify) : |  |  |  |  |\n| 2. How long have you treated this patient? Frequency? Date of last examination |  |  |  |  |\n| 3. Describe the nature, extent and frequency of any of the patient’s symptoms, especially those that might affect the safe operation of a motor vehicle. |  |  |  |  |\n| 4. Diagnoses (list): Treatment (medical/surgical/device): |  |  |  |  |\n| 5. List the kind, quantity and frequency of any medication with which the patient is being treated. |  |  |  |  |\n| 6. Is the disease or condition controlled? Yes ❑ No ❑ |  |  |  |  |\n| 7. If applicable, give dates and results of last EKG, EEG, blood pressure, HGBAIC or any other relevant test (specify) . |  |  |  |  |\n\n\n| Last name, First name, and DOB |  |  |  |\n| --- | --- | --- | --- |\n| 8. From a medical standpoint only, is the patient capable of safe and competent driving?\u003Cbr>❑ Yes ❑ No-DENIAL-do not issue driver's license |  |  |  |\n| 9. Recommended restrictions for Driving:\u003Cbr>❑ Daylight Only ❑ Corrective Lenses ❑ Mechanical Aids\u003Cbr>❑ Prosthetic Aids ❑ Outside Mirrors ❑ Automatic Transmission ❑ None |  |  |  |\n| 10. Recommended renewal interval:\u003Cbr>❑ 1 year ❑ 2 years ❑ 3 years ❑ 4 years\u003Cbr>❑ 8 years |  |  |  |\n| Physician’s name (print clearly) |  | Office telephone number |  |\n| Office Street Address | City, State ZIP Code |  |  |\n| Physician’s Signature | Date Signed |  | Physicians License Number |\n| Medical Report Form- Instructions for Physicians |  |  |  |\n| The final decision to accept or deny an application is the responsibility of the MVD.\u003Cbr>Physicians are asked to type or print all information carefully and legibly, to complete every section, and to follow these instructions when completing the Medical Report form:\u003Cbr>• Applicant Information:\u003Cbr>Please start with the applicant’s L!ST N!ME and print all information neatly;\u003Cbr>􀀒omplete all items, including Social Security Number (SSN); The SSN is confidential and will NOT be printed on the driver’s license or permit.\u003Cbr>• Physician’s Report:\u003Cbr>\\#1 Check ALL diseases or conditions that apply.\u003Cbr>\\#2 Indicate follow-up with the patient, including duration, frequency and most recent exam.\u003Cbr>\\#4 List SIGNIFI􀀒!NT DI!GNOSES ONLY, i;e; those that could affect the patient’s ability to drive safely and competently; Do NOT include diagnoses such as Thyroid, 􀀒OPD, 􀀒ancer, etc; if they do not actually affect the applicant’s ability to drive safely; Be sure to indicate treatment details, including dosage and level of control. Continue on another sheet of paper if necessary.\u003Cbr>\\#8 Indicate (yes or no) whether, from a medical standpoint only, the patient is capable of safe and competent driving.\u003Cbr>\\#9 Specify any driving restrictions that are appropriate based on the patien","cbCaipliHH9tXqXS","https://ap.wps.com/l/cbCaipliHH9tXqXS","pdf",306788,"English","# Physician’s Report\n## Disease or Condition and Treatment\n## Driving Capability, Restrictions, and Renewal Interval\n## Submission Instructions for Physicians","[{\"question\":\"What is the purpose of this Medical Report for the MVD?\",\"answer\":\"To determine, based on physician information, whether the applicant may continue to retain a New Mexico driver’s license. The MVD makes the final decision to accept or deny the application.\"},{\"question\":\"Which sections must physicians complete and answer carefully?\",\"answer\":\"Physicians must answer every section, check all applicable diseases/conditions, provide follow-up details, list significant diagnoses that could affect safe driving, include treatment details, and indicate whether the patient is capable of safe and competent driving.\"},{\"question\":\"What driving recommendations are requested in the form?\",\"answer\":\"The physician must recommend any driving restrictions (e.g., daylight only, corrective lenses, mechanical/prosthetic aids) and indicate the recommended renewal interval for the next driver’s license issuance.\"}]","NEW MEXICO TAXATION & REVENUE DEPARTMENT - MOTOR VEHICLE DIVISION - MEDICAL REPORT - Rev 8/23 | PDF",1789875072]