Form TC 94-176 template
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Breath Alcohol Ignition Interlock Physician Statement
This document is a Kentucky Transportation Cabinet form, specifically for the Division of Driver Licensing's Ignition Interlock Program. The form consists of three sections: Section 1 gathers driver/patient information including name, contact details, and medical condition; Section 2 has the driver/patient authorize the release of their medical records to KYTC and District Court; and Section 3 requires a physician's assessment of the patient's ability to use an ignition interlock device based on their medical condition and results from a pulmonary function test. The physician must provide their name, title, phone number, mailing address, current diagnosis of the patient, and the type and date of the last pulmonary function test performed.
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