Form BMV2310 "Request for Statement of Physician" - Ohio

What Is Form BMV2310?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Ohio Department of Public Safety;
  • 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 BMV2310 by clicking the link below or browse more documents and templates provided by the Ohio Department of Public Safety.

ADVERTISEMENT
ADVERTISEMENT

Download Form BMV2310 "Request for Statement of Physician" - Ohio

Download PDF

Fill PDF online

Rate (4.2 / 5) 22 votes
OHIO DEPARTMENT PUBLIC SAFETY
DX / FILE NUMBER
BUREAU OF MOTOR VEHICLES
REQUEST FOR STATEMENT OF PHYSICIAN
PATIENT DRIVER LICENSE NUMBER
PATIENT INFORMATION (Type or print in ink)
PATIENT FIRST NAME
LAST NAME
MI
DATE OF BIRTH
ADDRESS
CITY
STATE
ZIP CODE
PATIENT PHONE NUMBER
Check here if this is a name or address change.
RELEASE OF INFORMATION
I hereby authorize and request information regarding my physical and mental condition
be released to the Driver License Division, Bureau of Motor Vehicles.
PATIENT SIGNATURE
DATE
X
PHYSICIAN’S STATEMENT
If new patient, are records of previous physician available?
Yes
No
PREVIOUS PHYSICIAN NAME
ADDRESS
CITY
STATE
ZIP CODE
Is this patient being treated by another physician for any condition not being treated by you?
Yes
No
OTHER TREATING PHYSICIAN NAME
ADDRESS
CITY
STATE
ZIP CODE
If yes, should the BMV contact the physician referenced above regarding driving privileges of this patient?
Yes
No
Patient history and / or physical reveal the following:
Yes
No Vision abnormalities or eye disease (not correctable by eyeglasses)
Yes
No Musculoskeletal disorder (including loss of limb)
Yes
No Cardiovascular disease (e.g., Stroke, Angina, Heart failure, Hypertension)
Yes
No Respiratory disease (e.g., Emphysema, Asthma)
Yes
No Diabetes Mellitus and/or other Endocrine disorders
Insulin Dependent
Yes
No
Yes
No Neurological disease (e.g., Epilepsy, Multiple Sclerosis, Parkinson’s disease)
Yes
No Impairment due to alcohol or drugs
Yes
No Psychiatric disorders
Yes
No Cognitive Impairment
Yes
No Other medical disorders which could interfere with driving ability
EXPLANATION REQUIRED FOR ALL ANSWERS ABOVE.
IMPLEMENTATION OF SECTIONS 4507.20; 4507.08 AND 4507.081 OHIO REVISED CODE, REQUIRES THE FOLLOWING
INFORMATION BE PROVIDED:
1. How long has the condition(s) existed?
CONDITION
NO. OF YEARS
NO. OF MONTHS
CONDITION
NO. OF YEARS
NO. OF MONTHS
2. Give date of last episode or exacerbation.
CONDITION
YEAR
MONTH
CONDITION
YEAR
MONTH
2A. If #2 is not applicable, how long has the condition been under effective medical control?
CONDITION
NO. OF YEARS
NO. OF MONTHS
CONDITION
NO. OF YEARS
NO. OF MONTHS
RESTRICTED – PII
BMV 2310 10/19 [760-0310] Page 1 of 2
OHIO DEPARTMENT PUBLIC SAFETY
DX / FILE NUMBER
BUREAU OF MOTOR VEHICLES
REQUEST FOR STATEMENT OF PHYSICIAN
PATIENT DRIVER LICENSE NUMBER
PATIENT INFORMATION (Type or print in ink)
PATIENT FIRST NAME
LAST NAME
MI
DATE OF BIRTH
ADDRESS
CITY
STATE
ZIP CODE
PATIENT PHONE NUMBER
Check here if this is a name or address change.
RELEASE OF INFORMATION
I hereby authorize and request information regarding my physical and mental condition
be released to the Driver License Division, Bureau of Motor Vehicles.
PATIENT SIGNATURE
DATE
X
PHYSICIAN’S STATEMENT
If new patient, are records of previous physician available?
Yes
No
PREVIOUS PHYSICIAN NAME
ADDRESS
CITY
STATE
ZIP CODE
Is this patient being treated by another physician for any condition not being treated by you?
Yes
No
OTHER TREATING PHYSICIAN NAME
ADDRESS
CITY
STATE
ZIP CODE
If yes, should the BMV contact the physician referenced above regarding driving privileges of this patient?
Yes
No
Patient history and / or physical reveal the following:
Yes
No Vision abnormalities or eye disease (not correctable by eyeglasses)
Yes
No Musculoskeletal disorder (including loss of limb)
Yes
No Cardiovascular disease (e.g., Stroke, Angina, Heart failure, Hypertension)
Yes
No Respiratory disease (e.g., Emphysema, Asthma)
Yes
No Diabetes Mellitus and/or other Endocrine disorders
Insulin Dependent
Yes
No
Yes
No Neurological disease (e.g., Epilepsy, Multiple Sclerosis, Parkinson’s disease)
Yes
No Impairment due to alcohol or drugs
Yes
No Psychiatric disorders
Yes
No Cognitive Impairment
Yes
No Other medical disorders which could interfere with driving ability
EXPLANATION REQUIRED FOR ALL ANSWERS ABOVE.
IMPLEMENTATION OF SECTIONS 4507.20; 4507.08 AND 4507.081 OHIO REVISED CODE, REQUIRES THE FOLLOWING
INFORMATION BE PROVIDED:
1. How long has the condition(s) existed?
CONDITION
NO. OF YEARS
NO. OF MONTHS
CONDITION
NO. OF YEARS
NO. OF MONTHS
2. Give date of last episode or exacerbation.
CONDITION
YEAR
MONTH
CONDITION
YEAR
MONTH
2A. If #2 is not applicable, how long has the condition been under effective medical control?
CONDITION
NO. OF YEARS
NO. OF MONTHS
CONDITION
NO. OF YEARS
NO. OF MONTHS
RESTRICTED – PII
BMV 2310 10/19 [760-0310] Page 1 of 2
DX / FILE NUMBER
PATIENT DRIVER LICENSE NUMBER
3. Is medication prescribed?
Yes
No If yes, please list medications.
1.
3.
5.
2.
4.
6.
4. If medication is prescribed, has your experience with this patient indicated that he / she can be
depended upon to take the medication regularly and as instructed?
Yes
No
5. If you have discontinued patient’s medication, give date of termination.
YEAR
MONTH
6. In your professional opinion, is this patient’s condition(s), on this date, sufficiently under effective medical
control to operate a motor vehicle?
PLEASE NOTE: IF YOU ANSWER “YES” TO PARTS B, C, or D BELOW, THE EXAM WILL BE CONDUCTED NOW.
THE EXAM(S) WILL BE CONDUCTED AT A DRIVER LICENSE EXAM STATION.
A.
Yes. This patient should be permitted to retain driving privileges.
B.
Yes. This patient should be permitted to retain driving privileges only if they can pass a partial driver license
exam which consists of a vision screening and a road test for driving and maneuverability.
C.
Yes. This patient should be permitted to retain driving privileges only if they can pass a vision exam.
D.
Yes. This patient should be permitted to retain driving privileges only if they can pass a complete driver
license exam which consists of a vision screening, written test of Ohio’s laws and signs, and a road test
for driving and maneuverability.
E.
No.
This patient should not be permitted to retain driving privileges.
7. In your professional opinion, should this patient be reevaluated in the future for continued driving privileges.
Yes
No
If yes, reevaluation is required:
Once every six (6) months
Once every year
At time of driver license renewal (4 years or less depending on expiration date of current driver license or temporary
permit)
(Print or type)
PHYSICIAN’S NAME
PHONE NUMBER
DATE
ADDRESS
CITY
STATE
ZIP CODE
PHYSICIAN’S SIGNATURE
PHYSICIAN’S LICENSE NUMBER
X
NOTE TO PHYSICIAN: PLEASE MAKE A COPY FOR YOUR RECORDS.
OHIO BUREAU OF MOTOR VEHICLES, ATTN: SPECIAL CASE / MEDICAL UNIT, P.O. BOX 16784, COLUMBUS, OH 43216-6784
RESTRICTED – PII
BMV 2310 10/19 [760-0310] Page 2 of 2
Page of 2