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The form must be signed and dated by both the applicant and medical provider, then returned within 30 days; otherwise driving privileges are canceled. 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The physician must sign and date the form as required, and you also must sign and date it for review.","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},308514,1790066579,{"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":52,"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":145},1099514068035,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","NORTH CAROLINA DIVISION OF MOTOR VEHICLES MEDICAL REVIEW UNT – 3112 MAIL SERVICE CENTER, RALEIGH NC 27697-3112  \n\n| Full Name (Print) |  |\n| --- | --- |\n| Driver License/Customer Number |  |\n| Street Address |  |\n| City, State, Zip |  |\n\nTo Whom It May Concern:  \nDue to the following conditions, the Medical Review Unit of the Division of Motor Vehicles must review your ability to continue to safely operate a motor vehicle:  \n- General Physical Condition  \nThe enclosed Medical Report Form must be completed by your physician and returned to the Medical Review Unit within 30 days. If the completed form is not received within this timeframe, your driver license will be canceled until the Medical Report is received. Your physician only needs to complete the sections that are relevant to your condition. If you are unable to meet the 30 day deadline, please contact us as soon as possible at (919) 861-3809 to discuss your options.  \nPlease give this matter your immediate attention to avoid delays in your medical evaluation and to maintain your driving privileges.  \nIf you wish to be considered for removal from the Medical Review Program, please submit a written request with your name, date of birth, and driver license number to the Medical Review Program, 3112 Mail Service Center, Raleigh, NC 27697-3112. More information and a copy of the removal request form can be found on the Division of Motor Vehicles website.  \nWe will provide a written response within 30 days.  \nSincerely,  \nAssistant Director of Medical Review Enclosure  \nNORTH CAROLINA DIVISION OF MOTOR VEHICLES  \nINSTRUCTIONS FOR COMPLETING THE MEDICAL REPORT FORM  \nTo ensure your medical documents are promptly reviewed, please follow the steps below:  \n1. The Medical Report Form must be signed and dated by both you and your medical provider in order to be reviewed.  \n2. Please take the form to a physician who is licensed to practice medicine in North Carolina or any other US state. Your physician only needs to complete the sections of the form that are relevant to your specific health condition(s) .  \n3. Mail the completed form to the Division of Motor Vehicles, Medical Review Unit, 3112 Mail Service Center, Raleigh, NC 27699-3112. The form may also be faxed to (919) 733-9569.  \nThis information is necessary to determine your fitness to safely operate a motor vehicle. If the completed Medical Form is not received within 30 days, your driving privilege will be cancelled. If you need additional time, please contact our office at (919) 861-3809 as soon as possible.  \nNORTH CAROLINA DIVISION OF MOTOR VEHICLES  \nCONSENT FORM  \n\n| Full Name (Print) |  |\n| --- | --- |\n| Driver License/Customer Number |  |\n| Street Address |  |\n| Date of Birth |  |\n| County |  |\n| Name of Physician |  |\n\nI hereby authorize my doctor/counselor named above to give any examination they deem necessary for the purpose of determining my physical fitness to operate a motor vehicle. I understand this authorization includes permission for this information to be reviewed by a medical advisor approved by the Division for the purposes of a recommendation to be rendered to determine my driving needs and abilities.  \n\n| Signature of Applicant |  |\n| --- | --- |\n| Parent/Guardian (if minor) |  |\n| Phone Number |  |\n\nAre you? ☐ Retired ☐ Disabled What is your occupation?    \nWhat type of vehicle do you drive? ☐ Automobile ☐ School Bus ☐ CMV ☐ Other  Does your job require driving? ☐ Yes ☐ No  \nTo Physician  \nWhen completing the Medical Report Form, please consider the physical, cognitive, and emotional abilities required for the safe operation of a motor vehicle, as they relate to both the patient and public safety.  \nPlease answer all questions and complete all applicable sections of the enclosed packet, which outlines medical conditions relevant to driving. If you answer “Yes” to any condition, be sure to complete all corresponding questions on the subsequent pages. Questions related to conditions marked “No” do n","cbCaibpG8AYZrJrv","https://ap.wps.com/l/cbCaibpG8AYZrJrv","pdf",1982275,"English","# Instructions for completing the Medical Report Form\n## Timing, signing, and return requirements\n## Selecting the licensed physician and relevant sections\n## Mailing and fax submission details\n## Patient medical history and consent form instructions","[{\"question\":\"What is the purpose of the DMV Medical Review Unit request?\",\"answer\":\"The Medical Review Unit must review your ability to continue safely operating a motor vehicle based on medical conditions and overall fitness.\"},{\"question\":\"What happens if the completed Medical Report Form is not returned within 30 days?\",\"answer\":\"If the completed form is not received within 30 days, your driver license will be canceled until the Medical Report is received.\"},{\"question\":\"Who must complete the Medical Report Form and how should sections be handled?\",\"answer\":\"A licensed physician must complete the relevant sections related to your condition(s). The physician must sign and date the form as required, and you also must sign and date it for review.\"}]","NORTH CAROLINA DIVISION OF MOTOR VEHICLES - MEDICAL REVIEW UNIT - INSTRUCTIONS FOR COMPLETING THE MEDICAL REPORT FORM | PDF",1789869282,25]