Model Driver Screening and Evaluation Program
Volume II: Maryland Pilot Older Driver Study

 

Figure 50.
Letter Sent to Subjects
in the Medical Referral Sample

HEALTH INQUIRY COVER PAGE, Driver Control Division

MOTOR VEHICLE ADMINISTRATION, Department of Transportation, 6601 Ritchie Highway, N.E., Glen Burnie, MD 21062 

Health Inquiry Package Questions? Please Call: 1-410-768-7361 or TTY For the Deaf 1-800-492-4575 

NOTICE DATE:

 DUE DATE FOR ALL FORMS:

The Motor Vehicle Administration has received information that indicates you may have a medical condition that could affect your ability to drive safely. Three forms are enclosed. When properly completed, these forms often allow our Medical Advisory Board (MAB) to make an evaluation about your fitness for driving. These forms are: 

  1. Medical Advisory Board Health Questionnaire: your medical history and your understanding of your overall situation are most valuable in helping us develop an accurate appreciation of your condition. Your completed questionnaire will be reviewed carefully by at least one MAB doctor. Please be candid: the information you provide will be treated with the professional confidentiality appropriate to any personal medical communication. All MAB doctors and members of the administrative staff which supports them are bound by their own ethical standards and the Maryland Vehicle Law (paragraph 16-118(d)) to ensure the contents of MAB records are used only to determine qualification to drive and are never disclosed to others. We must use this questionnaire in our review of the great variety of clinical problems evaluated by the MAB - medical, surgical, psychiatric, substance abuse, and so forth; it also may be used in driver safety research projects. Some of the questions might seem unrelated to your situation, but these often turn out to be important for us, so we hope you will be willing to answer all of the questions. 
  2. Consent for Release of Confidential Information: please provide the name, address, and phone number of both your primary care physician and other doctors or treatment providers who’ve been involved in your care so we’ll be able to contact them if that should become necessary. 
  3. Physician’s Report: we hope your doctor will explain your clinical condition on this form in sufficient detail to enable the MAB to estimate the risk, if there is any, to highway safety. Please fill out Section 1 and then ask your doctor to complete the form and return it to us within two weeks of the date our letter was sent to you. If you and your doctor prefer, you may enclose the completed Physician’s Report with the other forms you return to us. If you feel our understanding of your condition will require information from more than one physician, you may reproduce the form enclosed or, you may contact your Case Manager and additional forms will be sent to you. 
  4. Driver Safety Screening: as part of the review process, we will conduct several driver safety screening tests. Please contact (fill in contact name) at (410) xxx-xxxx who will schedule the screening at one of our MVA full-service offices. Following the screening and review of all medical documentation, you will be further advised. 

Please respond promptly. Our commitment to highway safety requires when a driver fails to provide the information requested by the due date, we must render a conservative decision about suspension of the driving privilege. If a suspension is necessary, the right to appeal the decision and the process for doing so will be explained. 

CASE MANAGER:

DATE:

TELEPHONE: