Form 1528-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name, social security number, and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill out the patient’s mailing address, including city, state, and zip code. This ensures that any correspondence reaches the correct location.
4. In the Driver and Patient section, respond to all questions regarding driving habits and medical history. This includes how many trips are made weekly and any incidents involving law enforcement.
5. Proceed to the Physician section where you will enter examination details. Ensure that all relevant medical conditions are checked accurately based on your assessment.
6. Finally, review all entries for completeness and accuracy before signing. Once satisfied, save your document for submission.

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