Form DS-874C "Supplement to Medical Examination of Driver Report Under Article 19-a" - New York

What Is Form DS-874C?

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-874C 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-874C "Supplement to Medical Examination of Driver Report Under Article 19-a" - New York

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SUPPLEMENT TO: Medical Examination
of Driver Report Under Article 19-A
Driver Last Name
Driver First Name
M.I.
Client ID #
Date
This form is to be used ONLY as a supplement to the Medical Examination form (DS-874), and should be attached to that form
when completed. This form (DS-874C) is not required to be used, but if additional space is needed by the examining medical
staff or the driver being examined, this is the proper form to be used.
HEALTH HISTORY (additional driver and/or medical examiner comments and information)
PHYSICAL EXAMINATION (additional comments)
MEDICAL EXAMINER’S CERTIFICATION & REMARKS (additional remarks)
DS-874C (6/15)
reset/clear
reset/clear
SUPPLEMENT TO: Medical Examination
of Driver Report Under Article 19-A
Driver Last Name
Driver First Name
M.I.
Client ID #
Date
This form is to be used ONLY as a supplement to the Medical Examination form (DS-874), and should be attached to that form
when completed. This form (DS-874C) is not required to be used, but if additional space is needed by the examining medical
staff or the driver being examined, this is the proper form to be used.
HEALTH HISTORY (additional driver and/or medical examiner comments and information)
PHYSICAL EXAMINATION (additional comments)
MEDICAL EXAMINER’S CERTIFICATION & REMARKS (additional remarks)
DS-874C (6/15)
reset/clear
reset/clear