Ignition Interlock Medical Evaluation Form
This form is used by doctors to evaluate a patient's ability to use an ignition interlock device. It includes diagnosis details, medication information, and pulmonary function test results. It must be completed by a physician and mailed to the Bureau of Motorist Compliance.
Edit, Download, and Sign the Ignition Interlock Medical Evaluation Form
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, ensure all personal and medical details are accurately provided. A board-certified specialist must complete the evaluation sections. Submit the filled form to the mentioned address.
How to fill out the Ignition Interlock Medical Evaluation Form?
1
Complete the patient's personal information at the top.
2
Have a board-certified doctor fill out the medical evaluation sections.
3
Attach a copy of the pulmonary function test if applicable.
4
Ensure the doctor signs and provides their contact details.
5
Mail the completed form to the Bureau of Motorist Compliance.
Who needs the Ignition Interlock Medical Evaluation Form?
1
Patients required to use an ignition interlock device but have a medical condition.
2
Doctors evaluating patients for ignition interlock device usage.
3
Motorists with respiratory conditions that may affect their ability to use the device.
4
Healthcare professionals specializing in pulmonary medicine.
5
State motor vehicle agencies processing ignition interlock exemptions.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Ignition Interlock Medical Evaluation Form along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Ignition Interlock Medical Evaluation Form online.
You can easily edit this PDF on PrintFriendly using our online editor. Adjust any information or add new details directly within the form. Save and download the edited version instantly.
Add your legally-binding signature.
Sign the PDF directly on PrintFriendly using our integrated signature tool. Simply upload or draw your signature onto the form. Save the signed document with ease.
Share your form instantly.
Share the PDF effortlessly on PrintFriendly by using our sharing options. Send it via email, generate a sharable link, or directly share it on social media platforms. Collaborate efficiently by sharing the document.
How do I edit the Ignition Interlock Medical Evaluation Form online?
You can easily edit this PDF on PrintFriendly using our online editor. Adjust any information or add new details directly within the form. Save and download the edited version instantly.
1
Upload the PDF to PrintFriendly.
2
Use the editor to make the necessary changes.
3
Insert text, images, or your signature as required.
4
Review the edited document for accuracy.
5
Save and download the final version.
What are the instructions for submitting this form?
To submit this form, mail it to the Bureau of Motorist Compliance, Medical Review Section, MS 86, Neil Kirkman Building, Tallahassee, Florida 32399-0570. Ensure all sections are completed, and that the form is signed by a board-certified physician. Attach any required documents such as recent pulmonary function test results. Submitting this form accurately and promptly is crucial for compliance with ignition interlock requirements.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form before the ignition interlock device installation date in 2024 or 2025.
What is the purpose of this form?
The purpose of this form is to provide a medical evaluation for patients required to use an ignition interlock device due to legal requirements. It assists in determining if the patient has any medical condition that impairs their ability to use the device. The form also allows for potential adjustments or exemptions based on the patient's health condition.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The full name of the patient.
- 2. DOB: The date of birth of the patient.
- 3. Date: The date the form is being completed.
- 4. Driver License#: The driver's license number of the patient.
- 5. Telephone #: The contact telephone number of the patient.
- 6. Diagnosis: Current medical diagnosis impacting the patient's ability to use the IID.
- 7. Medications: List of current medications the patient is taking.
- 8. Pulmonary function test: A copy of a recent pulmonary function test to be attached.
- 9. Physician's signature: Signature of the evaluating physician.
- 10. Physician's contact details: Contact information of the evaluating physician including address and phone number.
What happens if I fail to submit this form?
Failing to submit this form may result in non-compliance with legal requirements for ignition interlock device usage.
- Legal Consequences: Non-compliance may lead to fines or further legal action.
- Driving Restrictions: The patient may be restricted from driving until the form is submitted and approved.
How do I know when to use this form?
- 1. Medical Evaluation: When a patient's condition affects their ability to use the IID.
- 2. Legal Compliance: To comply with legal requirements for ignition interlock installation.
- 3. Waiver Request: To request a waiver or adjustment to the IID settings based on medical advice.
Frequently Asked Questions
What is the purpose of this form?
This form evaluates a patient's ability to use an ignition interlock device.
Who must complete this form?
It must be completed by a board-certified pulmonologist or relevant specialist.
How can I fill out the form?
Use PrintFriendly's PDF editor to complete and save the form.
Can I attach additional documents?
Yes, you can attach a copy of the pulmonary function test and other relevant documents.
How do I sign the form?
Use PrintFriendly's signature tool to sign the form digitally.
How do I submit the form?
Mail the completed form to the Bureau of Motorist Compliance at the provided address.
Can I share the form electronically?
Yes, PrintFriendly allows you to share the form via email or a sharable link.
What should I do if I need to edit the form?
You can make edits directly on PrintFriendly before saving and downloading.
Who needs this form?
Patients with medical conditions affecting their use of an ignition interlock device, and their evaluating doctors.
What happens if I don't submit the form?
Failure to submit the form may result in non-compliance with ignition interlock requirements.
Related Documents - Interlock Medical Form
Andhra Pradesh State Road Transport Corporation Student Bus Pass Application
The Andhra Pradesh State Road Transport Corporation (APSRTC) Student Bus Pass Application form is for students up to SSC who need to apply for a bus pass for the academic year 2024-2025. This form includes personal details, school details, route details, and requires a bonafide certificate. Completing this form allows students to travel on APSRTC buses between their residence and school at a concessional fare.
NYC Section 8 Request to Move Form
The NYC Section 8 Request to Move Form is for participants in good standing to move with continued assistance. Participants must meet specific criteria and obtain necessary approvals. The form includes options for non-emergency and emergency moves.
Cheyenne Transit ADA Paratransit Eligibility Application
This file includes the application and instructions for Cheyenne Transit's ADA Paratransit service. It details the eligibility criteria and provides guidelines on how to complete the form. The document must be filled out in full and submitted to determine eligibility for Paratransit service.
Council-Manager Government Roles and Responsibilities Guide
This file provides detailed information about the roles and responsibilities of key officials in a council-manager government structure, including the mayor, city manager, and elected officials. It also explains how residents can participate in the government decision-making process.
Passenger and School Bus Driver Application
This file provides detailed instructions and forms required for obtaining a Commercial Driver License (CDL) with a passenger or passenger/school bus endorsement in New Jersey. It includes fingerprinting information, medical examiner certificate requirements, and a declaration form. Applicants must complete the form, print, and sign it before visiting an Agency or the New Jersey Motor Vehicle Commission.
Facility Clearance (FCL) Orientation Handbook - March 2021
This handbook provides a comprehensive orientation to the Facility Clearance (FCL) process. It outlines responsibilities, deadlines, and guidance. It includes detailed process information and required forms.
Service Member's Individual Transition Plan Checklist
This file is a checklist intended for service members to document and certify the achievement of career readiness standards as they transition out of the military. It includes sections for personal and family needs assessment, evaluation of military service benefits and acquired skills, career readiness standards, and contact information for supporting agencies. The checklist must be completed and verified by the service member, transition counselor, and unit commander prior to separation.
Bangladesh Judicial Service Commission Form Instructions
This document provides detailed instructions for filling out and submitting the Bangladesh Judicial Service Commission form, including essential deadlines and required fields.
NORKA, RØD S - Government of Kerala Undertaking File
This document is issued by the Government of Kerala and pertains to various government-related undertakings. It provides important instructions and details necessary for various procedures. Users should follow the guidelines carefully to ensure compliance.
GOVERNMENT OF PUNJAB DEPARTMENT OF PERSONNEL MANUAL 2019
This document is a manual by the Government of Punjab's Department of Personnel, outlining various personnel policies and instructions issued in the year 2019. It includes amendments, performance indicators, appointment procedures, and relevant rules for civil services and recruitment. The manual serves as a comprehensive guide for personnel management and related administrative processes.
Oklahoma DOT Roadway Design CADD Standards Manual
The Oklahoma DOT Roadway Design CADD Standards Manual effective April 1, 2015 details the best practices for all related engineering work. Following these standards ensures readability, uniformity, and proficiency in design plans. This manual is essential for designers working with or for the Oklahoma Department of Transportation.
Affordable Connectivity Program Application Form FCC Form 5645
FCC Form 5645 is an application form for the Affordable Connectivity Program (ACP) that provides monthly internet service discounts and a one-time device benefit for qualifying low-income consumers. The form includes sections for personal information, identity verification, and household details. Instructions for submission and required documentation are also provided.
