Form DS-703 "Article 19-a Bus Driver's Blood Pressure Follow-Up by Driver's Health Care Provider" - New York

What Is Form DS-703?

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 June 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form DS-703 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-703 "Article 19-a Bus Driver's Blood Pressure Follow-Up by Driver's Health Care Provider" - New York

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ARTICLE 19-A BUS DRIVER’S BLOOD PRESSURE FOLLOW-UP
BY DRIVER’S HEALTH CARE PROVIDER
NYS DMV COMMISSIONER’S REGULATIONS PART 6.10
NOTE:
This form may be used in conjunction with the Examination to Determine Medical Condition of Driver
Under Article 19-A (DS-874), or with the federal medical form if it is being used in lieu of the DS-874.
:
BUS DRIVER’S NAME
(Must correspond to name on driver’s license)
DATE OF BIRTH:
CLIENT/LICENSE ID NUMBER (from Driver License):
I,
, am acting as the above-
(Print Health Care Provider’s Name)
named bus driver’s health care provider. He/she is under my care, monitoring, and treatment (if necessary),
for high blood pressure. His/her condition is controlled by (indicate which):
¨
Diet
¨
Medication (identify):
¨
Other means (explain):
Health Care Provider’s License or Certificate Number
Issuing State
Health Care Provider’s Address:
Health Care Provider’s Phone:
His/her blood pressure reading today is:
Systolic:
Diastolic:
X
Health Care Provider’s Signature
Date
dmv.ny.gov
DS-703 (6/15)
reset/clear
reset/clear
ARTICLE 19-A BUS DRIVER’S BLOOD PRESSURE FOLLOW-UP
BY DRIVER’S HEALTH CARE PROVIDER
NYS DMV COMMISSIONER’S REGULATIONS PART 6.10
NOTE:
This form may be used in conjunction with the Examination to Determine Medical Condition of Driver
Under Article 19-A (DS-874), or with the federal medical form if it is being used in lieu of the DS-874.
:
BUS DRIVER’S NAME
(Must correspond to name on driver’s license)
DATE OF BIRTH:
CLIENT/LICENSE ID NUMBER (from Driver License):
I,
, am acting as the above-
(Print Health Care Provider’s Name)
named bus driver’s health care provider. He/she is under my care, monitoring, and treatment (if necessary),
for high blood pressure. His/her condition is controlled by (indicate which):
¨
Diet
¨
Medication (identify):
¨
Other means (explain):
Health Care Provider’s License or Certificate Number
Issuing State
Health Care Provider’s Address:
Health Care Provider’s Phone:
His/her blood pressure reading today is:
Systolic:
Diastolic:
X
Health Care Provider’s Signature
Date
dmv.ny.gov
DS-703 (6/15)
reset/clear
reset/clear