25cc2599_Affairs_Forms_and_Publications__Description
[Form] Request for Medical Evaluation [Instructions] Complete the form with as much information as possible about the person and concern as possible. We need to be able to identify the person in question within our data. All forms must be signed and dated. If completed by law enforcement, then your department's name, telephone number and supervising officer's signature are required. If completed by a physician, then your Mass. Board of Registration number is required. Health Care Provider Definition: a registered nurse, licensed practical nurse, physician, physician's assistant, psychologist, physical therapist, occupational therapist, ophthalmologist, optometrist, osteopath, or podiatrist who is a licensed health care provider under the provisions of M.G.L., Chapter112. [Description] 
When there is a concern about a person's functional ability to operate a motor vehicle safely then it may be reported to the RMV. A valid report from anyone other than Law Enforcement or a licensed physician will trigger the need for a medical evaluation from a physician within 30 days. Information obtained directly from law enforcement or a physician is acted upon immediately. Health Care Provider Definition: a registered nurse, licensed practical nurse, physician, physician's assistant, psychologist, physical therapist, occupational therapist, ophthalmologist, optometrist, osteopath, or podiatrist who is a licensed health care provider under the provisions of M.G.L., Chapter112.
Massachusetts RMV - Medical Affairs Forms and Publications
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