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Functional ability evaluation medical report

Functional ability evaluation medical report 2026

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The document is a Functional Ability Evaluation Medical Report required by the Utah Driver License Division. It includes sections for the applicant to authorize healthcare professionals to disclose health information relevant to their ability to drive safely. The report also requires healthcare professionals to assess and indicate the applicant's safety assessment level based on various medical conditions, along with any recommended driving restrictions. The form must be signed by both the applicant and the healthcare professional.

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Click ‘Get Form’ to open the functional ability evaluation medical report in the editor.
Begin by filling out the top portion of the form. Enter your last name, first name, middle or maiden name, date of birth, and driver license or DPC number. Ensure all information is accurate.
Sign the authorization section to allow healthcare professionals to disclose relevant health information regarding your ability to operate a motor vehicle safely.
Next, move to the bottom portion for completion by a healthcare professional. They will assess safety levels and mark appropriate categories based on your health conditions.
Ensure that your healthcare professional provides their printed name, degree, signature, state license number, and contact details before submitting the form.

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functional ability evaluation medical report utah

Why did i get a functional ability evaluation medical report utah DMV medical form Dld form utah Dld 134 rev 05 2025 The division might at times require a driver to undergo a review examination true false Medical form for drivers license How to report someone driving on a suspended license How to renew DOT medical card

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