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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'Legal Name of Entity' in the designated field. Ensure that you type or print clearly for accurate processing.
- Next, review the list of services provided and check the box next to each service you are contracting to provide: CLASS, DAHS, MDCP, and PHC/FC/CAS.
- In the 'Name of Authorized Representative' field, type or print the name of the individual authorized to sign on behalf of your entity.
- Finally, add your signature in the designated area and enter the date of signing. This confirms that you have read the Pre-Application Orientation Guide.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4.9 Satisfied (486 Votes) |
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What are the DOT requirements for diabetes?
Per the FMCSA, anyone who has recently experienced a severe hypoglycemic episode must complete form MCSA-5870. Form MCSA-5870 is a four-page form comprised of several sections, each featuring a series of questions designed to gauge an applicants ability to control diabetes and its associated symptoms.
What is the dot form for diabetes?
Lastly, if the medical examiner uses a test to search for diabetic conditions, they are searching for hemoglobin A1c, which has a limit of 10% for the DOT physical. However, if the A1c levels are higher than 8%, the medical examiner may recommend further testing and monitoring.
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