District of Columbia Department of Motor Vehicles - Medical Referral Form > Step 1 of 2: Submit

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

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) *

* indicates required fields

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