Form 1528-2025

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4.8 out of 5

130 votes

The document is a Physician's Statement form (Form 1528) from the Missouri Department of Revenue, intended for evaluating a patient's fitness to operate a motor vehicle. It includes sections for patient information, medical history, and physician assessments regarding various health conditions that may affect driving ability. The form requires the physician to determine if the patient is capable of driving safely and responsibly, and it allows for recommendations on restrictions or further evaluations if necessary.

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Click ‘Get Form’ to open it in the editor.
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.
Fill out the patient’s mailing address, including city, state, and zip code. This ensures that any correspondence reaches the correct location.
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 or accidents.
Proceed to the Physician section where you will input examination details. Indicate if you are a regular provider for the patient and document any relevant medical conditions that may affect driving ability.
Finally, review all entries for completeness and accuracy before signing. Use our platform's features to save your progress or print directly if needed.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (130 Votes)
2012	4.4 Satisfied (288 Votes)

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