Medical Affairs Forms and Publications


Form Description Instructions
Application for Disabled Parking Placard/Plate Special Placards and Plates are available for vehicles that transport medically disabled drivers and passengers. This application is a two page form. The applicant is required to complete the first page of the form and the second page of the form MUST be completed by a Massachusetts licensed physician, chiropractor or nurse practitioner. Once you complete the first page you should take both pages of the form to your physician, chiropractor or nurse practitioner to complete the second page. Please return both completed pages to the RMV for processing. The completed form can either be mailed to the Medical Affairs Bureau or submitted to any RMV Branch Location.
Lost Placard Form This form is used when your placard has been lost or stolen. Any replacement, extension or renewal of a placard, for any reason, invalidates any previous placard that may have been issued. Print the name and address of the placard holder (person placard has been issued to). Please provide placard number (if known). Please supply at least one of the following for the placard holder: 1) Massachusetts License/ID Number; 2) Social Security Number; or 3) Date of Birth. All affidavits must be signed and dated by the placard holder or legal guardian.
Application for Intrastate Medical Waivers To Operate Class A,B, Or C Commercial Motor Vehicles This form is used to request a medical waiver to operate Class A, B, or C Commercial Motor Vehicles. A copy of the results of a recent DOT medical examination performed pursuant to 49 CFR 391.43, upon which the examining physician has indicated that you are only qualified to operate a commercial motor vehicle with an intrastate medical waiver. Your employment driving record for the previous five years. Your current employer's letter(s) of recommendation, including a certification that you will be engaged only in intrastate commerce within the Commonwealth of Massachusetts.
Medical Evaluation Form This form is to be completed by your physician when the Registry has a question concerning your medical/physical qualification for driving. Additionally, this form may be used to regain your driving privilege after the voluntary surrender of your license. PLEASE NOTE: If your license is in revoked or suspended status, then your doctor may need to review documentation including a police report if the suspension is a result of an incident reported to the RMV by law enforcement. If your license is revoked or suspended, then you must see a Hearings Officer. Print your full name and License or Social Security number in the appropriate space. Please sign and date the form. Have your physician complete the questions concerning your medical history.
Request for Medical Evaluation 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.
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.
Loss of Consciousness Form This form is to be completed by your physician when the Registry has a question concerning your medical/physical qualification for driving. Additionally, this form may be used to regain your driving privilege after the voluntary surrender of your license. PLEASE NOTE: If your license is in revoked or suspended status, then your doctor may need to review documentation concerning your license status prior to this form being accepted. If your license is revoked or suspended, then please consult with a hearing officer or Driver Control staff prior to having this form completed. This form is to be completed by your physician when the Registry has a question concerning your medical/physical qualification for driving related to loss of consciousness or altered consciousness . Additionally, this form may be used to regain your driving privilege after the voluntary surrender of your license. PLEASE NOTE: If your license is in revoked or suspended status, then your doctor may need to review documentation concerning your license status prior to this form being accepted. If your license is revoked or suspended, then please consult with a hearing officer or Driver Control staff prior to having this form completed.
Class D and M Vision Screening Certificate This form is used in lieu of the RMV eye exam and must be signed by an optometrist or physician. Have your eye care provider complete and sign this form in the appropriate sections.  Bring the completed Vision Screening Certificate with you when you come in to apply for or to renew your license.
CDL Vision Screening Certificate This form is used in lieu of the RMV eye exam and must be signed by an optometrist or physician. Have your eye care provider complete and sign this form in the appropriate sections.  Bring the completed Vision Screening Certificate with you when you come in to apply for or to renew your license.
Your Health and Driving Safely The Registry of Motor Vehicles' guide for physicians and other medical professionals concerning medical qualification for driver licensing. N/A
Application for Tinted Glass Waiver Tinted Glass Waivers can only be issued to private passenger vehicles owned or operated by the person certified by the physician as being photophobic/photosensitive. This application must be signed by a medical doctor. Please supply name, address, license/Social Security Number, telephone number and Registration number of vehicle the tint is to be applied. The remainder of the form must be completed by your physician.
Application for Temporary Placard for Holders of Disability Plates For holders of HP plates, this form is used when you request a temporary placard for travel in another vehicle. Print the name and address of the HP plate holder (disabled person plate is registered to). Please provide plate number. Reason or "good cause" for the temporary placard must be noted on the form.
Voluntary Surrender Affidavit This form is to be used if you wish to surrender your driving privileges for medical reasons in order to receive a Mass ID for no fee. Please supply license number, print name, and sign and date form. Actual license or statement that license is no longer in your possession must be included with this form.


Printer icon, opens print window Print This Page


Translation Disabled  | Translation Support
Massachusetts Department of Transportation

MassDOT Twitter massrmv MassDOT Facebook MassDOT Youtube MassDOT Blog MassDOT Site Policies MassDOT Developer Resources