Medical Applications and Forms
The expiration date on the Medical Examination Report Form, MCSA-5875, Medical Examiner's Certificate, MCSA-5876, Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, and the Vision Evaluation Report, Form MCSA–5871 has been updated to 12/31/2024, and all forms are posted below. Please note that the only change to the forms is the change in the OMB expiration date from 11/30/2021 to 12/31/2024.
Medical Examiners should start using the forms with the 12/31/2024 date as soon as possible. However, MEs that have purchased these forms in bulk, or require time to reprogram electronic system forms, may continue to use the old forms until stocks have been depleted or forms have been reprogrammed but should transition to use of the new forms as quickly as possible. Based on this guidance, SDLAs are encouraged to continue to accept these forms.
- Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870
- Medical Examination Report (MER) Form, MCSA-5875
- Medical Examiner's Certificate (MEC), Form MCSA-5876
- Vision Evaluation Report, Form MCSA–5871
- 391.41 CMV Driver Medication Form, MCSA-5895 (optional)
This package has been removed due to the update of the Diabetes Standard. For more information please visit the New Diabetes Standard Overview Webinar.
This package has been removed due to the update of the Vision Standard. For more information please visit the New Vision Standard Overview Webinar.
- Federal Hearing Exemption Application (NEW)
- Federal Hearing Exemption Application (RENEWAL)
- Medical Release Form (Hearing) SAMPLE
- Medical Release Form