Transcription of Form 1528 - Physician's Statement
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Example: dental hygienist
Form 1528 - Physician's Statement
Pursuant to Section RSMo, completing this report does not violate physician or patient privilege, and when in good faith, the physician shall be immune from any civil liability that might otherwise result from making this report. INSTRUCTIONS: Use your best clinical judgement as you REVIEW AND COMPLETE ALL SECTIONS. Attach additional sheets as necessary. Base severity ratings within each category on your overall assessment of impairment relative to the driving task. FORM1528(REV. 04-2019)MISSOURI DEPARTMENT OF REVENUEDRIVER LICENSE BUREAU, BOX 200 TELEPHONE: (573) 751-2730301 WEST HIGH STREET, ROOM 470 FAX: (573) 522-8174 JEFFERSON CITY, MO 65105-0200 WEB SITE: PHYSICIAN S Statement DRIVER OR PATIENTSECTIONPATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY)PATIENT S MAILING ADDRESS CITY STATE ZIP CODEI hereby authorize and accept that: My physician will conduct a medical examination to determine my fitness to operate a motor vehicle safely and responsibly.
Compliant with medications & basic requirements of self-care? Yes Somewhat No Does this patient have: Cardiovascular Disease Yes No Cardiac Arrhythmia Yes No Heart Failure Yes No History of MI Yes No History of Syncope Yes No AHA Functional Capacity (circle level if applicable) I II III IV
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