Form MAB 118 Psychiatric Evaluation Form - Massachusetts

Form MAB118 or the "Psychiatric Evaluation Form" is a form issued by the Massachusetts Registry of Motor Vehicles.

The form was last revised in February 1, 2018 and is available for digital filing. Download an up-to-date Form MAB118 in PDF-format down below or look it up on the Massachusetts Registry of Motor Vehicles Forms website.

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Psychiatric Evaluation Form
Registry of Motor Vehicles ● Medical Affairs
P.O. Box 55889 ● Boston, MA 02205-5889
FAX: 857-368-0018 ● PHONE: 857-368-8020
I hereby authorize the person completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the Registry of Motor Vehicles.
Applicant’s Signature: __________________________________________________ Date: ________________________
This form must be fully completed by a physician: a medical doctor who is licensed to practice in the
Commonwealth of Massachusetts or a psychiatric nurse practitioner.
A. Patient Information
Last Name
First Name
Middle Name
Suffix
Date of Birth (MM/DD/YYYY)
License #
Reported Condition
The Registry of Motor Vehicles has received information that the patient named above may have a condition which could
affect his/her ability to operate a motor vehicle. Please complete the following so that the RMV can fairly evaluate the
impact of your patient’s condition upon his/her ability to operate a motor vehicle safely:
1. Please describe the patient’s psychiatric condition, using DSM-V or ICD-10 diagnosis:
2. Please describe the extent, frequency, and control of the symptoms of the patient’s condition or disability which may
affect his/ her ability to operate a motor vehicle (i.e., oriented in all spheres, dissociative episodes, etc.):
3. Is the patient’s psychiatric condition or disability likely to interfere with his/her mental or physical
ability to operate a motor vehicle safely? ...................................................................................................  Yes  No
4. If condition involves seizure or any type of altered or loss of consciousness, please state type and date of last episode:
5. Is patient on any medication(s)?
 Yes  No If Yes, please list medication(s) with dosage(s):
6. Are these medications, separately or in combination, likely to interfere with his/her ability to operate
a motor vehicle safely? ..............................................................................................................................  Yes  No
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MAB118_0218
Psychiatric Evaluation Form
Registry of Motor Vehicles ● Medical Affairs
P.O. Box 55889 ● Boston, MA 02205-5889
FAX: 857-368-0018 ● PHONE: 857-368-8020
I hereby authorize the person completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the Registry of Motor Vehicles.
Applicant’s Signature: __________________________________________________ Date: ________________________
This form must be fully completed by a physician: a medical doctor who is licensed to practice in the
Commonwealth of Massachusetts or a psychiatric nurse practitioner.
A. Patient Information
Last Name
First Name
Middle Name
Suffix
Date of Birth (MM/DD/YYYY)
License #
Reported Condition
The Registry of Motor Vehicles has received information that the patient named above may have a condition which could
affect his/her ability to operate a motor vehicle. Please complete the following so that the RMV can fairly evaluate the
impact of your patient’s condition upon his/her ability to operate a motor vehicle safely:
1. Please describe the patient’s psychiatric condition, using DSM-V or ICD-10 diagnosis:
2. Please describe the extent, frequency, and control of the symptoms of the patient’s condition or disability which may
affect his/ her ability to operate a motor vehicle (i.e., oriented in all spheres, dissociative episodes, etc.):
3. Is the patient’s psychiatric condition or disability likely to interfere with his/her mental or physical
ability to operate a motor vehicle safely? ...................................................................................................  Yes  No
4. If condition involves seizure or any type of altered or loss of consciousness, please state type and date of last episode:
5. Is patient on any medication(s)?
 Yes  No If Yes, please list medication(s) with dosage(s):
6. Are these medications, separately or in combination, likely to interfere with his/her ability to operate
a motor vehicle safely? ..............................................................................................................................  Yes  No
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MAB118_0218
6. Please check one of the following categories:
I hereby certify that in my professional opinion and to a reasonable degree of medical certainty, one of the following:
 The patient named above is medically qualified to operate a motor vehicle safely.
 The patient named above is NOT medically qualified to operate a motor vehicle safely.
 I am unable to determine driving ability and recommend the patient undergo a competency road examination.
7. Please check one:
I have read the attached police report and am aware of the reported incident
involving my patient. ....................................................................................................................  Yes  No  N/A
8. Additional Comments:
B. Physician Certification
Massachusetts Board of
Physician’s /RN’s Name
Phone #
Registration #
Address
Street
City
State
Zip Code
I hereby certify, under the pains and penalties of perjury, that the information I have provided herein is true and
correct.
Signature: _____________________________________________________________ Date: _____________________
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MAB118_0218

Download Form MAB 118 Psychiatric Evaluation Form - Massachusetts

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