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Physician Certification Form
MSDPS MODERNIZATION USE CASE
This document is a Mississippi Department of Public Safety Physician Certification Form. The form includes patient information such as name, date of birth, and driver license number. The form also requires the physician to certify whether the patient has been diagnosed with diabetes or hearing impairment, and if so, to specify the type. For diabetic patients, the physician must indicate whether they are injection dependent, diet controlled, or oral dependent. For hearing-impaired patients, the physician must confirm that the patient meets the hearing loss requirements for a Hearing-impaired Driver indicator. The form also includes a section for persons with disabilities and requires the physician to certify if the applicant meets certain conditions that limit their mobility. The form must be signed by the physician and includes fields for their name, signature, date, and medical license number.
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