Connecticut Department of Motor Vehicles · Connecticut state form
Medical Form P-142M
Medical Form P-142M lets a patient and medical examiner provide information about the patient’s medical fitness to operate a motor vehicle safely.
- What this form is
- The patient completes Section A, and a licensed physician, physician assistant, or advanced practice registered nurse completes Sections B and C. The report asks about medical conditions, driving safety, and possible reporting requirements. The medical examiner must certify that they personally examined the patient within 90 days before completing the report. The form also includes an authorization for discussing the medical case.
- Who needs it
- Patients asked to provide medical information to the DMV, with a licensed physician, physician assistant, or APRN completing the examiner sections.
- Why it needs a notary
- The medical examiner’s signature must be notarized because the form includes a sworn statement. This can be done online with a commissioned online notary.
- How to submit it
- Submit it to the Connecticut agency named on the form.
Questions
Who completes Medical Form P-142M?
The patient completes Section A. A licensed physician, physician assistant, or advanced practice registered nurse completes Sections B and C based on a personal examination.
Does Medical Form P-142M need to be notarized?
Yes. The medical examiner’s sworn statement requires a notarized signature. The signature can be notarized online with a commissioned online notary.
When must the medical examination take place?
The form says the medical examiner must personally examine the patient within 90 days before completing the report.