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West Virginia DMV Medical Review Services

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West Virginia Department of Transportation
Division of Motor Vehicles
Medical Report Form

WV DMV Medical Review Services
PO Box 17030 • Charleston, WV 25317
Phone: (304) 926-3961 Fax: (304)957-0323

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PART I • TO BE COMPLETED BY THE DRIVER (You must complete Part I before presenting the medical form to your doctor.)

A.) Patient Authorization

The patient named below has been referred to the DMV Driver Services Division concerning their ability to operate a motor vehicle safely. This medical report must reflect the results of the licensed physician's personal examination of the patient performed within 90 days of this report being filed. It must be signed by the patient authorizing the physician to release this report and any attachments to DMV.

I hereby authorize the licensed physician completing and signing this medical report to release such report to DMV along with any other medical information necessary to determine my fitness to operate a motor vehicle safely.

PATIENT'S SIGNATURE

DATE

LICENSE NUMBER

PATIENT'S NAME (Please Print)

DATE OF BIRTH

TELEPHONE NUMBER

PATIENT'S ADDRESS (Street) (City) (State) (Zip Code)

PART II • TO BE COMPLETED BY THE EXAMINING PHYSICIAN (When the form is complete mail or fax it to WV DMV.)

B.) Applicant’s Medical History • This form must be signed by a licensed medical practitioner.

1. How long has applicant been your patient?

Date you last treated applicant before today:

Has the applicant ever had any of the following illnesses or conditions?
If YES, you must complete the appropriate sections under PART III.

C.) Details on Applicant’s Conditions or Illnesses • ONLY complete sections for questions answered with a YES under Section II.

A. DIABETES MELLITUS:

1. Age of onset: Does applicant take insulin or oral diabetic medication? Yes No If yes what kind and dosage?

2. Has applicant ever been in diabetic coma? Yes No If yes, how many times? Date of last coma:

3. Has the applicant had insulin reactions severe enough to impair judgment or ability to drive an automobile? Yes No

If yes, how many times? Date of last episode:

4. Does applicant have diabetic retinopathy? Yes No    5. Is applicant’s diabetic condition under adequate control? Yes No

B. MUSCULOSKELETAL DISORDER:

1. What type of musculoskeletal disorder does applicant have?

2. Are there any spastic or paralyzed muscles? Yes No If yes, briefly describe:

3. Has there been an amputation? Yes No If yes, what portion of the anatomy?

4. Does applicant require any orthopedic appliance or supports? Yes No If yes, what?

PART III • TO BE COMPLETED BY THE EXAMINING PHYSICIAN CONTINUED

C. EMOTIONAL OR MENTAL ILLNESS:

1. Has the applicant been treated for an emotional or mental illness? Yes No If yes, describe briefly:

2. Present medication (type and dosage):

Does medication affect mental alertness? Yes No

3. Does applicant demonstrate any mental retardation? Yes No If yes, describe briefly:

D. CARDIOVASCULAR DISORDER:

1. What type of cardiovascular disease does applicant have?

2. Functional capacity (AHA), check one:

Class I - No limitation of physical activity; ordinary physical activities cause no undue dyspnea, anginal pain or palpitation.
Class II - Slight limitation of physical activity; comfortable at rest and with mild exertion.
Class III - Marked limitation of physical activity; comfortable at rest but symptoms occur with mild activity.
Class IV - Complete limitation of physical activity; symptoms occur at rest.

3. Does applicant have congestive heart failure? Yes No    If yes, is it adequately controlled? Yes No

4. Does applicant have history of arrhythmia? Yes No If yes, state type and how it's controlled:

5. If applicant has hypertension, answer the following:

A. What is present BP reading?

B. Is there any indication of abnormal urinary function, hypertensive cerebrovascular damage, left ventricular hypertrophy, peripheral vascular disease, arterial-venous malformation, or any hypertensive abnormality? Yes No If yes, please specify:

6. Have there been syncopal episodes due to cardiovascular disease? Yes No Date of last episode:

7. Does applicant take medication regularly for a cardiovascular condition? Yes No If yes, state type and dosage?

E. ALCOHOL/DRUG PROBLEMS:

1. Has applicant been treated for alcoholism or drug dependency? Yes No If yes, when?

Where?

2. Does the patient drink alcoholic beverages now? Yes No If yes, to what extent?

PART III • TO BE COMPLETED BY THE EXAMINING PHYSICIAN (CONTINUED)

F. NEUROLOGICAL DISORDER:

1. Does the applicant have epilepsy or convulsive seizures? Yes No If yes, provide details below:

A. Date of onset: Date of last seizure: Brief description of seizures:

B. How often do they occur?

C. Do these seizures occur only during sleep (nocturnal epilepsy)? Yes No

D. Does applicant take medications for seizure control? Yes No If yes, provide details below:

When was present regimen of therapy initiated?

Please list medications and recent blood levels below:

Medication:

Medication:

E. Date of last EEG: Interpretation:

2. Has the applicant had “blackout” spells or fainting spells unrelated to epilepsy or diabetes? Yes No

If yes, specify cause if known:

Date of last episode:

3. Has the applicant suffered brain damage? Yes No If yes, describe briefly:

4. Does applicant show deficiency in mentation? Yes No

5. Does applicant suffer from poor coordination? Yes No

If yes, state cause:

PART IV • TO BE COMPLETED BY THE EXAMINING PHYSICIAN

D.) Examining Physician’s Comments, Recommendations, and Certification

1. In your professional opinion, can the applicant safely operate a motor vehicle? Yes No

2. Do you recommend periodic medical evaluations for driver license purposes? Yes No If yes, how often?

3. In your opinion, should there be any restrictions imposed such as: limitation of driving distance, daylight driving only, or no interstate driving? Yes No If yes, specify:

Physician’s Name (Please print in ink or type)

Medical License Number

State Of Issue

Business Address

City

State

Zip

Signature

Date

Telephone Number

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What the West Virginia DMV Medical Review Services Are

The West Virginia DMV Medical Review Services is the administrative process the West Virginia Division of Motor Vehicles uses to evaluate drivers whose medical conditions could affect safe vehicle operation. The review collects clinical records, physician statements, test results, and any required examinations to assess fitness to drive and to determine suitable restrictions, monitoring, or license actions. The process may include scheduled medical examinations, periodic reassessments, and documented appeal rights. Submissions must follow DMV instructions for format and authorization to permit release of protected health information.

Why a Formal Medical Review Matters

A formal medical review clarifies driving fitness, helps tailor license restrictions to clinical diagnoses, and ensures public safety while protecting driver rights. Accurate documentation reduces delays, supports consistent decisions, and provides a clear record for appeals or future reassessments.

Why a Formal Medical Review Matters

Who Typically Participates in a Medical Review

Typical users include the driver, treating clinicians, DMV medical staff, and legal representatives involved in fitness determinations.

  • Drivers with chronic or episodic medical conditions that may impair driving.
  • Treating physicians completing medical evaluation forms or supplying clinical records.
  • DMV examiners and case managers who review records and set restrictions.

Knowing each party’s role helps reduce processing time and ensures required documentation is submitted correctly.

Core Elements of a Complete Medical-Review Submission

Essential components of a professional medical-review submission help DMV staff assess medical fitness efficiently and document decisions for legal and medical follow-up.

Cover Letter

Include a concise cover letter summarizing the medical issue, key dates, and the purpose of submission to assist reviewers in prioritizing and contextualizing enclosed records.

Medical Records

Provide relevant clinic notes, recent diagnostic test results, current medication lists, and hospitalization summaries that directly address cognitive, sensory, or motor functions affecting driving ability.

Physician Statement

A treating clinician’s signed, dated statement should describe diagnosis, prognosis, testing performed, current treatment, and an explicit opinion on driving safety with suggested limitations or monitoring.

Functional Tests

Include objective assessments such as formal visual acuity/field reports, cognitive screening scores, neuropsychological evaluations, or polysomnography summaries that quantify impairment and recovery expectations.

Consent/Authorizations

Signed release forms permitting the DMV to obtain medical records are often required; use HIPAA-compliant authorization language and ensure patient initials or dates where applicable to avoid retrieval delays.

Follow-up Plan

Document suggested re-evaluation intervals, conditional licensing proposals, return-to-drive criteria, and monitoring plans that define when the treating clinician will provide updated information to the DMV.

Step-by-Step: Complete and Submit the Medical-Review Packet

Follow these steps to complete and submit the WV DMV medical-review packet accurately and include physician records and signed authorizations.

  • 01
    Gather Records: Collect relevant clinic notes, tests, and medication lists.
  • 02
    Complete Forms: Fill patient info, license number, dates, and signatures.
  • 03
    Physician Input: Request a signed physician statement and supporting tests.
  • 04
    Submit Packet: Mail or e-submit to WV DMV Medical Review unit.

How Submissions Are Processed by the DMV

Overview of submission routing, administrative triage, medical evaluation, and final license decision stages handled by the DMV.

  • Intake: DMV logs packet and verifies identity.
  • Clinical Review: Medical staff evaluates records and tests.
  • Exam Scheduling: If needed, DMV schedules in-person medical exam.
  • Decision: License modified, restricted, or suspended with notice.

Online Workflow Settings for eSubmission

Common online workflow settings for securely e-submitting and routing West Virginia DMV medical-review documents.

Field Configuration
Signing Method ESIGN click, typed, or drawn signature
Authentication Email link or SMS code; add ID check
File Formats PDF preferred; DOCX accepted; images allowed
Notifications Email confirmations and status updates to parties

Technical Requirements for Electronic Submission

Electronic submission requires compatible file types, secure signer authentication, and strict adherence to West Virginia DMV upload and formatting instructions.

  • File Types: PDF, DOCX, JPG accepted
  • Authentication: Email/SMS codes, ID checks
  • Integrations: Integrates with EHR and cloud storage

Typical Timelines and Response Expectations

Processing times vary by case complexity; expect initial review and request for additional information within 30–90 days in many cases.

Initial Acknowledgment:

DMV acknowledges receipt, often within 7–14 days.

Request for More Info:

Typically within 30–60 days of receipt.

Physician Response Deadline:

Provide physician reports within any DMV-specified timeframe, commonly 14–30 days.

Appeal Period:

Time to request a hearing varies; commonly 30 days from notice.

Re-evaluation Interval:

Follow-up exams or monitoring often required every 6–12 months.

Common Errors That Cause Delays

  • Submitting partial records or unsigned physician statements delays review and may trigger formal requests for missing information, lengthening overall processing.
  • Using different names, partial license numbers, or wrong birthdates prevents DMV from matching records to a driver file and causes rejections.
  • Scanned images rotated, low-resolution, or password-protected files can be unreadable and rejected by intake systems.
  • Omitting a signed HIPAA-compliant release prevents DMV from obtaining third-party records and can halt the review.

Consequences of Inaccurate or Missing Information

License Restriction: Temporary or permanent restrictions applied.
Suspension: Driver license may be suspended.
Criminal Penalty: Rare, for willful falsification.
Delayed Clearance: Longer process and administrative burden.
Insurance Impact: Possible higher premiums or coverage limits.
Employment Consequences: Job duties involving driving may be affected.

Representative Use Cases: How Medical Reviews Work in Practice

Two concise scenarios illustrate typical workflows and outcomes when medical evidence guides DMV decisions.

Neurology Clinic Submission

A clinic compiles clinic notes, EEG, and cognitive screening results into one packet to send to the DMV.

  • Physician provides a clear driving-safety opinion.
  • The DMV used the packet to issue a conditional license with periodic re-evaluation, reducing unnecessary suspension while protecting public safety.

Occupational Health Review

An occupational health service documents a worker’s seizure-free interval and medication plan before submitting to DMV.

  • Specialist includes return-to-drive criteria.
  • The DMV set a timed restriction and requested follow-up evidence, allowing the driver to continue employment subject to monitoring.

eSignature Vendor Comparison for Medical-Review Workflows

Compare common vendor pricing and core capabilities relevant to secure, HIPAA-aware medical-review submissions. Verify plan details and BAA availability directly with each vendor before selection.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (Premium tier) Yes Yes Yes Limited
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Key Milestones in the Medical-Review Process

A sequential view of principal milestones clarifies what to expect from submission through final administrative action.

01

Submission Logged

DMV records receipt and opens case file.

02

Initial Review

Medical staff screens records for completeness and urgency.

03

Additional Testing

Sign and schedule required examinations or specialist evaluations.

04

Final Decision

Administrative action issued with appeal information.

Frequently Asked Questions About West Virginia DMV Medical Review Services

Answers to common questions address who must submit records, acceptable electronic signatures, timelines, and what to include from clinicians.


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