Form DS-6 "Physician's Reporting Form" - New York

What Is Form DS-6?

This is a legal form that was released by the New York State Department of Motor Vehicles - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the New York State Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DS-6 by clicking the link below or browse more documents and templates provided by the New York State Department of Motor Vehicles.

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Download Form DS-6 "Physician's Reporting Form" - New York

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PHYSICIAN’S REPORTING FORM
INSTRUCTIONS:
Parts 1 through 3
Please provide all of the information requested in
below, and sign and date the form.
This form is provided for use by a physician, physician assistant, or nurse practitioner 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, physician assistant 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 337, 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 dmv.ny.gov/olderdriver.
Please Note:
Based on the medical information submitted, our reviewer may ask for further medical details, or may request additional
information from a pertinent sub-specialist, ex: cardiologist; neurologist
Driver License
PART 1 - DRIVER IDENTIFICATION (please print)
Number
Last
First
M.I.
Date of Birth (if not known,
Name*
Name*
give approximate age)
Street
Address
City*
State
Zip Code
* Required information
PART 2 - DESCRIPTION OF THE DRIVER’S CONDITION
Have you treated this patient?
YES
NO
If Yes: 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/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
COMPLETING THIS REPORT
Certificate or Lic. No.
Specialty (Please specify)
Your name
(Print name in full)
State Where Licensed
Your Mailing Address
(Include Street & No.)
City
State
Zip Code
(Area Code) & Telephone Number
(
)
Date (Month/Day/Year)
Your Signature
X
(Sign name in full)
/
/
DS-6 (5/15)
reset/clear
reset/clear
PHYSICIAN’S REPORTING FORM
INSTRUCTIONS:
Parts 1 through 3
Please provide all of the information requested in
below, and sign and date the form.
This form is provided for use by a physician, physician assistant, or nurse practitioner 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, physician assistant 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 337, 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 dmv.ny.gov/olderdriver.
Please Note:
Based on the medical information submitted, our reviewer may ask for further medical details, or may request additional
information from a pertinent sub-specialist, ex: cardiologist; neurologist
Driver License
PART 1 - DRIVER IDENTIFICATION (please print)
Number
Last
First
M.I.
Date of Birth (if not known,
Name*
Name*
give approximate age)
Street
Address
City*
State
Zip Code
* Required information
PART 2 - DESCRIPTION OF THE DRIVER’S CONDITION
Have you treated this patient?
YES
NO
If Yes: 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/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
COMPLETING THIS REPORT
Certificate or Lic. No.
Specialty (Please specify)
Your name
(Print name in full)
State Where Licensed
Your Mailing Address
(Include Street & No.)
City
State
Zip Code
(Area Code) & Telephone Number
(
)
Date (Month/Day/Year)
Your Signature
X
(Sign name in full)
/
/
DS-6 (5/15)
reset/clear
reset/clear