Form P-40 "Initial Medical Request" - Connecticut

What Is Form P-40?

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

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Connecticut 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 P-40 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form P-40 "Initial Medical Request" - Connecticut

1259 times
Rate (4.4 / 5) 63 votes
INITIAL MEDICAL REQUEST
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
P-40 REV. 8-2017
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
Address incident of
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
The patient named below has been referred to the DMV Driver Services Division concerning their ability to safely operate a motor vehicle. This medical
report must reflect the results of the medical professional's (licensed physician, PA or APRN) personal examination of the patient performed within 90 days of
this report being filed. It must be signed by the patient authorizing the medical professional to release this report and any attachments to DMV.
I hereby authorize the medical professional completing and signing this medical
PATIENT'S SIGNATURE
DATE
report to release such report to DMV and/or Bureau of Rehabilitative Services
(BRS) along with any other medical information necessary to determine my
X
fitness to safely operate a motor vehicle.
PATIENT'S NAME (Please Print)
(Last)
(First)
(Initial)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
PATIENT'S ADDRESS (Street)
(City)
(State)
(Zip Code)
Indicate to the best of your knowledge any and all condition(s) pertaining to this patient.
Alcohol/Substance Abuse
Neurological/Neuromuscular
Alzheimer's/Dementia
Ophthalmologic
Cardiovascular/Hypertension
Orthopedic
Peripheral Vascular Disease
Cerebral Palsy
Psychiatric/Emotional Disorder
Cystic Fibrosis
Endocrine/Glandular
Pulmonary/Sleep Apnea
Other
Liver/Renal Failure
Narcolepsy
HOW LONG HAVE YOU BEEN TREATING THIS PERSON AND FOR WHAT CONDITION(S)?
CONDITION:
TREATMENT BEGAN:
DATE OF LAST EXAMINATION
IF TREATED BY ANOTHER PHYSICIAN, PLEASE INDICATE NAME, ADDRESS AND SPECIALTY OF PHYSICIAN.
OFFICE ADDRESS (Include Zip Code)
PHYSICIAN'S NAME (Please Print or Type)
PHYSICIAN'S SPECIALTY
This individual has NO medical matters which would affect his/her ability to safely operate a motor vehicle.
I do not have sufficient information to determine this person's ability to operate a motor vehicle.
Considering this patient’s condition(s), do you believe this person should be road tested and/or evaluated for
YES
NO
special equipment requirements?
MEDICAL PROFESSIONAL CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion
of this report. I swear or affirm under penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to
penalties for perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.
MEDICAL PROFESSIONAL'S NAME (Please Print or Type)
OFFICE ADDRESS (Include Zip Code)
TELEPHONE NUMBER
MEDICAL PROFESSIONAL'S LICENSE NUMBER
MEDICAL PROFESSIONAL'S SPECIALTY
(
)
MEDICAL PROFESSIONAL'S SIGNATURE
DATE REPORT COMPLETED
INITIAL MEDICAL REQUEST
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
P-40 REV. 8-2017
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
Address incident of
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
The patient named below has been referred to the DMV Driver Services Division concerning their ability to safely operate a motor vehicle. This medical
report must reflect the results of the medical professional's (licensed physician, PA or APRN) personal examination of the patient performed within 90 days of
this report being filed. It must be signed by the patient authorizing the medical professional to release this report and any attachments to DMV.
I hereby authorize the medical professional completing and signing this medical
PATIENT'S SIGNATURE
DATE
report to release such report to DMV and/or Bureau of Rehabilitative Services
(BRS) along with any other medical information necessary to determine my
X
fitness to safely operate a motor vehicle.
PATIENT'S NAME (Please Print)
(Last)
(First)
(Initial)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
PATIENT'S ADDRESS (Street)
(City)
(State)
(Zip Code)
Indicate to the best of your knowledge any and all condition(s) pertaining to this patient.
Alcohol/Substance Abuse
Neurological/Neuromuscular
Alzheimer's/Dementia
Ophthalmologic
Cardiovascular/Hypertension
Orthopedic
Peripheral Vascular Disease
Cerebral Palsy
Psychiatric/Emotional Disorder
Cystic Fibrosis
Endocrine/Glandular
Pulmonary/Sleep Apnea
Other
Liver/Renal Failure
Narcolepsy
HOW LONG HAVE YOU BEEN TREATING THIS PERSON AND FOR WHAT CONDITION(S)?
CONDITION:
TREATMENT BEGAN:
DATE OF LAST EXAMINATION
IF TREATED BY ANOTHER PHYSICIAN, PLEASE INDICATE NAME, ADDRESS AND SPECIALTY OF PHYSICIAN.
OFFICE ADDRESS (Include Zip Code)
PHYSICIAN'S NAME (Please Print or Type)
PHYSICIAN'S SPECIALTY
This individual has NO medical matters which would affect his/her ability to safely operate a motor vehicle.
I do not have sufficient information to determine this person's ability to operate a motor vehicle.
Considering this patient’s condition(s), do you believe this person should be road tested and/or evaluated for
YES
NO
special equipment requirements?
MEDICAL PROFESSIONAL CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion
of this report. I swear or affirm under penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to
penalties for perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.
MEDICAL PROFESSIONAL'S NAME (Please Print or Type)
OFFICE ADDRESS (Include Zip Code)
TELEPHONE NUMBER
MEDICAL PROFESSIONAL'S LICENSE NUMBER
MEDICAL PROFESSIONAL'S SPECIALTY
(
)
MEDICAL PROFESSIONAL'S SIGNATURE
DATE REPORT COMPLETED