District of Columbia Department of Motor Vehicles - Medical Referral Form

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

 *
 *
 *


 *
 *
 *
 *

Requestor Information (Person Completing Request)

 *
 *
 *
 *
 *
 *
 *
 *
 *

Description of Driver's Condition

 *
 *

Attachments

 *

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

 *

* indicates required fields

Web form by