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Get and Sign Printable Utah State Functional Ability Evaluation Medical Report Form 2014-2022

Name: Functional Ability Evaluation Medical Report - Fill Out and Sign Printable PDF Template | signNow
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Healthcare professional(s) to disclose specific health information regarding my physical, mental and emotional condition relevant to my ability to safely operate a motor vehicle, to the Utah Driver License Division. I understand that if I fail to sign this authorization my driving privilege may be affected. I understand that this information will be classified as a private record in accordance with GRAMA (UCA 63G-2-202). Individuals who are entitled to have a “private” record disclosed to them...

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UT DLD 134 2015

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