Where should I send the form?

Submit the completed medical form to the Kansas Division of Vehicles office or upload portal specified in your DMV correspondence. If you lack a portal option, follow the postal or in‑person delivery instructions provided by the agency.

Can the provider sign electronically?

Yes. Electronic signatures meeting ESIGN and UETA standards are generally acceptable, provided the eSignature platform preserves an audit trail, supports retention, and if PHI is involved, the platform is HIPAA-compliant under a written BAA.

Is a notarization required?

Notarization is typically not required for DMV medical reports in most states, including Kansas, but specific situations or supporting affidavits may request notarized statements; verify with the Division of Vehicles if unsure.

What if the DMV asks for more information?

Respond promptly with the requested records or clarifications. Delays or incomplete responses can lead to temporary restrictions, reexamination requests, or administrative action.

How is privacy protected?

Medical information is protected under HIPAA when transmitted through covered entities or their business associates. Use secure, encrypted transmission and document any patient consent for disclosure to the DMV.

How do I correct errors on a submitted form?

Provide an amended form signed and dated by the provider and clearly marked as a replacement. Include a brief explanation of the correction and any supporting documentation to expedite administrative acceptance.

Electronic Signature
Templates
Healthcare
Kansas Division of Vehicles Medical Form

Kansas Division of Vehicles Medical Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Kansas Division of Vehicles Medical Form

PLEASE RETURN COMPLETED MEDICAL FORMS TO:

PH: Telephone: (785) 368-8971

FAX: (785) 296-5857

STATE OF KANSAS DIRECTOR OF VEHICLES

MEDICAL/VISION UNIT

915 HARRISON STREET

PO BOX 2188

TOPEKA KS 66601-2188

KANSAS DIVISION OF VEHICLES MEDICAL FORM

GENERAL INFORMATION & HISTORY – TO BE FILLED OUT BY THE PATIENT

NAME:

DRIVER LICENSE #:

DOB:

ADDRESS:

CITY/STATE/ZIP:

PHONE #:

Currently enrolled in Driver’s Education?

Yes No

If yes, instructor name & phone number:

RELEASE OF INFORMATION

Permission is granted for release of all medical information concerning me to the Kansas Division of Vehicles by all medical professionals filling out this form.

SIGNATURE OF PATIENT

DATE

To the Medical and/or Psychological Professionals: Please complete the sections of this report applicable to this patient’s conditions. You assume no responsibility in making this report other than that of truthfully representing the facts as they appear in your professional judgment. The information on this form must be from an examination within the last 90 days.

Instructions:

Please answer each question and fill out the entire form carefully and legibly.
Indicate yes or no whether from a medical and/or psychological standpoint only, this patient is capable of safely operating a motor vehicle.
Please note that if the patient has had a recent loss or alteration of consciousness, the exam date must be a full six months after the date of the last occurrence.
Specify any driving restrictions that are appropriate based on the patient’s disease or medical and/or psychological condition.
If the patient should be seen by a specialist, a form must be taken to the specialist for completion. If the patient requires multiple exams, they may make copies of this form or contact the Medical/Vision Unit for additional copies. All treating physicians must complete a set of forms.

If you have questions, please call 785-368-8971.

SECTION I: PHYSICIAN’S REPORT

1. In your opinion, does this patient have a medical condition that could affect the patient’s ability to safely operate a motor vehicle?

Yes No Uncertain

If yes or uncertain please explain:

2. Has the patient had any loss/lapse of consciousness, seizure activity, fainting or syncopal event in a waking state?

Yes No

If yes please indicate the date of the last occurrence (MM/DD/YYYY)

Was the seizure or loss of consciousness an isolated incident?

Yes No

Has the patient had any other occurrences within the last 3 years?

Yes No

3. Should this patient be referred to a specialist (such as a neurologist or psychologist) to determine their ability to safely operate a motor vehicle?

Yes No

If yes, what type

4. Physician’s Comments:

5. Indicate below which restrictions may apply to the patient’s license if issued or continued: Maximum 6 restrictions.

Corrective Lenses Daylight Hours Only No Interstate Driving Outside Business Area Within City Limits Licensed Driver in Front Seat Automatic Transmission Outside Mirror Mechanical Aid Prosthetic Aid Miles From Home (5-30 in 5 mile increments)

6. Should an actual test of the patient’s driving ability be administered?

Yes No

7. Should an annual medical report be required to be filed with the Division of Vehicles?

Yes No

8. This patient is capable of safely operating a motor vehicle. (Driver must be considered a safe candidate in order to request a drive test.)

Yes No

9. Does this patient require a vision exam?

Yes No

Name of Medical Professional & License # (Please print)

Date of Examination

Medical Professional’s Specialty

Signature of Medical Professional

Address

Date Signed

Phone

What the Kansas Division of Vehicles Medical Form Is

The Kansas Division of Vehicles Medical Form documents medical conditions, impairments, and physician assessments that may affect a driver's ability to operate a motor vehicle safely. It is completed by a licensed healthcare provider and submitted to the Kansas Division of Vehicles when a medical issue could impair driving, inform fitness-to-drive decisions, and establish required restrictions or monitoring by the agency.

Why this medical form matters for licensure and safety

The form provides authoritative clinical information the Division of Vehicles relies on to assess driving fitness, to set restrictions, and to protect public safety while preserving license access when appropriate.

Who completes and reviews this medical form

Several parties interact with the Kansas Division of Vehicles Medical Form depending on the situation and role.

Drivers with new or worsening medical conditions that could impair driving, including seizures, syncope, stroke, or severe visual loss.
Licensed healthcare providers who evaluate the patient and record objective findings and clinical opinions for the DMV.
Kansas Division of Vehicles staff and medical consultants who review submissions and determine restrictions or need for reexamination.

Each participant has distinct responsibilities: the clinician documents clinical facts, the driver provides consent, and the DMV applies regulatory standards.

Step-by-step: filling the medical form

Follow these sequential steps to complete and submit the Kansas Division of Vehicles Medical Form accurately.

01

Collect documents: Gather current license, medical records, and test results.
02

Complete form: Provider documents diagnosis, exam findings, and limitations.
03

Sign and date: Provider signs and records license number and contact details.
04

Submit to DMV: Send by the method the Kansas Division of Vehicles accepts.

How submission and review typically flow

The form goes from clinician to DMV and then through an internal medical review process before outcomes are communicated to the driver.

Clinician completes: Clinical facts and opinion entered with supporting test data.
Driver transmits: Driver or clinician sends the completed form to the Division of Vehicles.
DMV reviews: Medical staff or consultants evaluate the submission and records.
Decision issued: DMV applies restrictions, monitoring, or reexamination requirements.

Online completion and authentication settings

Configure an electronic workflow to collect structured clinical answers, sign securely, and preserve an audit trail acceptable for regulatory review.

Field mapping	Match PDF fields to clinical inputs for clear data capture.
Signature type	Use an e-signature with audit trail for provider signature.
Authentication	Require email or SMS code for signer verification.
Document format	Submit as flattened PDF/A to preserve layout and signatures.
Retention policy	Store signed copies with versioning and access controls.

Integrations and technical formats for eSubmission

Choose tools and formats that maintain integrity and accessibility of medical data when submitting electronically.

File formats: PDF and PDF/A are preferred for signed medical forms.
Authentication options: Email, SMS, or advanced signer authentication available.
Integrations: Connectors for EHR and cloud storage may simplify uploads.

Ensure chosen platforms support HIPAA safeguards, audit trails, and reproducible signed PDFs for administrative review.

Timing expectations and typical processing windows

Timelines vary by office and caseload; plan for a medical review period and possible follow-up or reexamination requests.

Clinician completion timeframe:

Complete and sign at the time of clinical evaluation.

Submission window:

Submit as soon as the provider signs; delays hinder timely decisions.

DMV review period:

Processing usually requires multiple business days to several weeks.

Response to queries:

Provide any requested additional records within the deadline given.

Reexamination timing:

DMV may require follow-up exams at specified intervals.

Security and privacy attributes to verify

HIPAA Clearance: BAA required

Encryption: TLS 1.2/1.3 & AES-256

Audit Trail: Timestamped events

Access Control: Role-based permissions

File Integrity: Tamper-evident PDFs

Authentication: Multi-factor options

Consequences of incomplete or incorrect submissions

Processing Delays: Incomplete forms are rejected

License Action: Suspension or restriction possible

Insurance Impact: Coverage questions may arise

Legal Exposure: False statements carry penalties

Privacy Breach: Protected health information risk

Additional Exams: DMV may require repeat testing

Common preparation errors to avoid

Omitting the provider license number or contact details which prevents verification and causes rejection.
Describing symptoms generally rather than reporting objective findings such as test results and dates.
Submitting unsigned or undated provider sections that render the medical report invalid for administrative review.
Failing to retain a copy of the signed form and supporting records for the retention period required by HIPAA or state rules.

eSignature vendor pricing and feature snapshot

Compare common pricing and compliance features for eSignature providers; signNow is listed first for reference and HIPAA-capable options are noted.

	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	Yes, 7-day trial	No	No	No	No
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Real-world examples of electronic medical reporting

These examples show how organizations and practitioners streamline medical reporting with secure digital workflows and compliant signatures.

Optica Ventures

The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers.

The team reduced turnaround time on forms.
They retained secure audit trails and improved customer responsiveness while complying with recordkeeping requirements.

Fertility Centers

The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company.

Integration enabled direct uploads to records.
The result was faster patient intake workflows and consistent, auditable consent records for clinical and administrative use.

Tips for accurate, compliant completion

Adopt these practices to reduce rejection risk and to ensure forms meet administrative and privacy standards.

Use objective data

Record tests, dates, and measurable findings rather than subjective summaries to support DMV decisions.

Verify identities

Confirm the driver identity matches DMV records to avoid processing delays.

Preserve privacy

Transmit PHI via HIPAA-compliant channels and document patient consent where required.

Keep copies

Retain signed originals and supporting records for the retention period applicable to your organization.

Representative signers and approvers

Licensed Provider

A physician, physician assistant, or advanced practice clinician completes clinical sections, signs, dates, and includes state license number and contact information for verification by the DMV.

Driver or Representative

The driver or an authorized representative provides consent, submits the completed form to the Division of Vehicles, and retains a copy for personal records and for insurer or employer needs.

Frequently asked questions about the medical form

Answers to common questions about completion, signature, submission, privacy, and next steps when the Kansas Division of Vehicles requests medical information.

Need help? Contact support

Where should I send the form?
Submit the completed medical form to the Kansas Division of Vehicles office or upload portal specified in your DMV correspondence. If you lack a portal option, follow the postal or in‑person delivery instructions provided by the agency.
Can the provider sign electronically?
Yes. Electronic signatures meeting ESIGN and UETA standards are generally acceptable, provided the eSignature platform preserves an audit trail, supports retention, and if PHI is involved, the platform is HIPAA-compliant under a written BAA.
Is a notarization required?
Notarization is typically not required for DMV medical reports in most states, including Kansas, but specific situations or supporting affidavits may request notarized statements; verify with the Division of Vehicles if unsure.
What if the DMV asks for more information?
Respond promptly with the requested records or clarifications. Delays or incomplete responses can lead to temporary restrictions, reexamination requests, or administrative action.
How is privacy protected?
Medical information is protected under HIPAA when transmitted through covered entities or their business associates. Use secure, encrypted transmission and document any patient consent for disclosure to the DMV.
How do I correct errors on a submitted form?
Provide an amended form signed and dated by the provider and clearly marked as a replacement. Include a brief explanation of the correction and any supporting documentation to expedite administrative acceptance.

Explore Templates

Minnesota Living Trust Minnesota Criminal History Check

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now