District of Columbia Department of Motor Vehicles - Medical Referral Form

Step 1 of 2: Submit

The Medical Referral process is a program where members of Law Enforcement, Medical Professionals, Motor Vehicle Administrations, and Concerned Relatives can report drivers whom they feel are no longer able to safely operate a motor vehicle due to a medical condition.

Only complete this form if you are a driver who is self-reporting or a member of Law Enforcement, Medical Professional, Motor Vehicle Administration, or Concerned Relative. Please note, age is not a consideration.

Upon review, DC DMV will investigate and take action as necessary. Identities of persons submitting Medical Referral reports will remain confidential.

Driver Information

Last Name (Driver Being Reported) First Name (Driver Being Reported) Middle Name (Driver Being Reported)

Gender Male Female

Street Address City, State Zip Code Driver Date of Birth/Apprx. Age Driver License Number Vehicle License Plate Number Driver Telephone Number Driver Email Address

Requestor Information (Person Completing Request)

Last Name First Name Address City State Zip Telephone Number Email Address Requestor Type Relationship to the driver you are reporting Badge/Professional License Number (For Law Enforcement and Medical/Healthcare Professionals Only) Organization/Agency Name (If applicable)

Description of Driver's Condition

Nature of Concern Circumstances that led to request

Attachments

Supporting Documentation

The making of a false statement on this form is a violation of DC Law and subject to fines and imprisonment (D.C. Official Code 22-2405)

“I certify under penalty of perjury that the information contained in the Medical Referral Form is true and correct."

Type Full Name (This represents your electronic signature)