Form MVD-10124 "Medical Report" - New Mexico

What Is Form MVD-10124?

This is a legal form that was released by the New Mexico Taxation and Revenue Department - a government authority operating within New Mexico. 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 Mexico Taxation and Revenue Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MVD-10124 by clicking the link below or browse more documents and templates provided by the New Mexico Taxation and Revenue Department.

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Download Form MVD-10124 "Medical Report" - New Mexico

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MVD–10124
REV. 05/15
NEW MEXICO TAXATION & REVENUE DEPARTMENT, MOTOR VEHICLE DIVISION
MEDICAL REPORT
Medical Advisory
Please be advised that the decision to allow an applicant to continue to retain his/her New Mexico driver’s license is
Board Use Only
contingent upon the information provided in this medical report. It is imperative, and in the best interest of the applicant
and the motoring public, that all questions be answered completely. This report may be reviewed by a physician or panel
of physicians, who may request additional medical information. This form will become part of the applicant’s record, is for
Approved
confidential use of the physician, panel or division, and may not be divulged to any person or used as evidence in any trial.
Denied
ALL INFORMATION MUST BE TYPED OR CLEARLY PRINTED
Applicant Information
Applicant’s Name (Last, First, Middle Initial)
Date of Birth
Mailing Address
City, State ZIP Code
Telephone Number
E-mail Address
Social Security Number
Driver’s License Number
Physician’s Report
DISEASE or CONDITION - Note: a) Provide details in #5 below for any box checked.
1.
 Neurological
 Cardiovascular
 Diabetes
 Psychological
 Dementia
 Hypoglycemia
 Epilepsy
 Loss of Consciousness
 Orthopedic/Prosthetic
 Other:
2.
How long have you treated this patient?
Frequency?
Date of last examination
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.
4.
Diagnoses (list):
Treatment (medical/surgical/device):
5.
List the kind, quantity and frequency of any medication with which the patient is being treated.
MVD–10124
REV. 05/15
NEW MEXICO TAXATION & REVENUE DEPARTMENT, MOTOR VEHICLE DIVISION
MEDICAL REPORT
Medical Advisory
Please be advised that the decision to allow an applicant to continue to retain his/her New Mexico driver’s license is
Board Use Only
contingent upon the information provided in this medical report. It is imperative, and in the best interest of the applicant
and the motoring public, that all questions be answered completely. This report may be reviewed by a physician or panel
of physicians, who may request additional medical information. This form will become part of the applicant’s record, is for
Approved
confidential use of the physician, panel or division, and may not be divulged to any person or used as evidence in any trial.
Denied
ALL INFORMATION MUST BE TYPED OR CLEARLY PRINTED
Applicant Information
Applicant’s Name (Last, First, Middle Initial)
Date of Birth
Mailing Address
City, State ZIP Code
Telephone Number
E-mail Address
Social Security Number
Driver’s License Number
Physician’s Report
DISEASE or CONDITION - Note: a) Provide details in #5 below for any box checked.
1.
 Neurological
 Cardiovascular
 Diabetes
 Psychological
 Dementia
 Hypoglycemia
 Epilepsy
 Loss of Consciousness
 Orthopedic/Prosthetic
 Other:
2.
How long have you treated this patient?
Frequency?
Date of last examination
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.
4.
Diagnoses (list):
Treatment (medical/surgical/device):
5.
List the kind, quantity and frequency of any medication with which the patient is being treated.
6. Is the disease or condition controlled?
 Yes
No
7. If applicable, give dates and results of last EKG, EEG, blood pressure, HGBAIC or any other relevant test (specify).
8. From a medical standpoint only, is the patient capable of safe and competent driving?
 Yes
 No
9.
Recommended restrictions:
 Daylight Only
 Corrective Lenses
 Mechanical Aids
 Prosthetic Aids
 Outside Mirrors
 Automatic Transmission
10.
Recommended renewal interval:
 1 year
 2 years
 3 years
 4 years
 8 years
 DENIAL - do not issue driver’s license
Physician’s name (print clearly)
Office telephone number
Office Address
City, State ZIP Code
Physician’s Signature
Date Signed
License Number
Medical Report Form - Instructions for Physicians
The Motor Vehicle Division’s Medical Advisory Board may review the Medical Report and make recommendations with respect to the
patient’s application for a new or renewal driver’s license or permit.
The final decision to accept or deny an application is the responsibility of the MVD.
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:
• Applicant Information:
Please start with the applicant’s LAST NAME and print all information neatly.
Complete all items, including Social Security Number (SSN). The SSN is confidential and will NOT be printed on the driver’s license
or permit.
• Physician’s Report:
#1 Check ALL diseases or conditions that apply.
#2 Indicate follow-up with the patient, including duration, frequency and most recent exam.
#4 List SIGNIFICANT DIAGNOSES ONLY, i.e. those that could affect the patient’s ability to drive safely and competently. Do NOT include
diagnoses such as Thyroid, COPD, Cancer, 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.
#8 Indicate (yes or no) whether, from a medical standpoint only, the patient is capable of safe and competent driving.
#9 Specify any driving restrictions that are appropriate based on the patient’s disease or medical condition.
#10 Indicate recommended time period to next license renewal date based on the patient’s disease or medical condition and the
appropriate frequency of reevaluation. Check DENIAL only if, from a medical standpoint only, the patient is not capable of safe and
competent driving.
• Physician’s name, contact information, signature, date and license number:
Please complete ALL sections NEATLY.
• Return completed form to MVD Driver Services Bureau:
Please return the completed Medical Report to Attn: Drivers Services Bureau, Motor Vehicle Division, P.O. Box 1028, Santa Fe,
NM 87504-1028.
Otherwise, the driver may take the Medical Report to a MVD field office for issuance of a permit or driver’s license based on the physician’s
recommendations.
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