Laserfiche WebLink
MEDICAL REPORT DOT-H 2058(4;09) <br /> FOR <br /> Applicant's Name <br /> NOTICE TO APPLICANT: <br /> Please take this form to your doctor(licensed M.D.or D.O.).You are responsible for any expense involved. <br /> The Medical Advisory Board will review your medical report that will be identified by number only.The board will <br /> provide an opinion regarding your fitness to drive safely based on the guidance in the Medical Conditions Affecting <br /> Drivers. <br /> The County's Examiner of Drivers will review the board's opinion and decide whether you meet the standards <br /> required to operate a motor vehicle in the State of Hawaii. <br /> NOTICE TO MEDICAL EXAMINER: <br /> This applicant is required to undergo a medical examination to provide the driver licensing administrator information <br /> to decide whether the physical and mental standards to be licensed in this State are met.Your report will be reviewed <br /> by this agency and the Medical Advisory Board before the applicant is licensed.State laws make the licensing <br /> administrator responsible for the licensing action and your medical report is strictly advisory.Please be assured that <br /> your report will be used to grant driving privileges commensurate with driving ability while considering driving need <br /> and public safety. <br /> Please complete the form for the medical condition in question so that we may be properly informed about the <br /> medical conditions that might impair safe driving ability.If your examination reveals other conditions that in your <br /> professional opinion might present a hazard to driving safely,please provide the information.Consult with other <br /> medical authorities,if necessary. <br /> The applicant is responsible for any professional fee for this examination.The AUTHORIZATION FOR RELEASE <br /> OF MEDICAL INFORMATION form is for your protection;it should be signed by the applicant and kept in your <br /> files. <br /> Thank you for your assistance in this program. <br /> ......................................................................................................................................................................................... <br /> AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION <br /> I hereby authorize the release of my medical history to the county examiner of drivers for deciding my eligibility for <br /> a driver's license by. <br /> Name of M.D.or D.O. <br /> Signature of applicant Date <br />