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Form 5839 – Physician’s Statement and Authorization (Fillable PDF)

  1. Language English
  2. Country USA
  3. Activity Driver's License
  4. State Missouri
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Form 5839 – Physician’s Statement and Authorization (Fillable PDF)

Form 5839 is the official Missouri Physician’s Statement and Authorization required when you want a medical alert notation placed on a driver’s license or non‑driver ID. The form must be completed by a licensed health‑care provider and presented at the time of application.

What Is Form 5839 and Who Needs It?

This form is used under Section 302.205, RSMo to certify medical conditions that affect driving ability. It is typically needed by individuals with conditions such as epilepsy, diabetes, vision impairments, or any health issue that the Missouri Department of Revenue deems relevant for a medical alert.

How to Complete Form 5839 Online

Instead of downloading the PDF and editing it manually, simply click the "Fill out this form" button on this page. The Formize PDF Filler app will load, allowing you to complete every field directly in your browser. Once finished, you can save or print the completed form.

Common Mistakes to Avoid on Form 5839

  • Leaving any required fields blank – the form will be rejected.
  • Using an unsigned or non‑licensed provider’s signature.
  • Providing outdated contact information for the physician.
  • Submitting a scanned copy with low resolution; use the online filler for a clear PDF.

Where to Submit the Completed Form

After filling out Form 5839, bring the printed copy (or a saved electronic version) to your local Missouri Department of Revenue office when applying for or renewing a driver’s license or ID. The office will verify the medical information before adding the alert notation.

FAQs About Form 5839

Below are answers to the most common questions about this form. For more details, refer to the downloadable PDF linked at the bottom of the page.

FAQ
  • Who is authorized to sign Form 5839?

    Only a licensed physician, osteopathic doctor, or other qualified health‑care professional can sign the form.

  • Can I submit a scanned copy of the form?

    Yes, but the scan must be clear and legible. Using the online Formize filler ensures a high‑quality PDF.

  • Do I need to attach medical records?

    Generally no, unless the Department of Revenue specifically requests supporting documentation.

  • How long does the medical alert stay on my license?

    The alert remains until the physician provides a new statement indicating the condition has resolved.

  • Is there a fee to file Form 5839?

    No separate fee is charged for the medical statement; any standard licensing fees still apply.

  • What if my physician’s signature is missing?

    The form will be rejected. Contact the physician to obtain a proper signature before submission.

HOW TO

How to fill out Form 5839 for free, online in 4 easy steps:

  1. 1
    Click the Fill‑out Button
    Press the "Fill out this form" button on the page. The Formize PDF Filler loads in your browser.
  2. 2
    Enter All Required Information
    Complete each field – patient details, physician’s credentials, and the medical condition description.
  3. 3
    Save or Print the Completed Form
    When all sections are filled, click "Save" to download a copy or "Print" to obtain a hard‑copy for submission.
  4. 4
    Submit to the Missouri Department of Revenue
    Take the printed form (or a saved PDF) to your local DMV office when applying for or renewing your license.
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Driving License Application Forms

Form 5839 is one of Driver's license forms that are documents used in the process of obtaining or renewing a driver's license, which is an official government-issued document that permits individuals to operate a motor vehicle on public roads. These forms may vary depending on the jurisdiction, but they generally include the following:

Application Form: This form is used to apply for a driver's license and typically asks for personal information such as name, address, date of birth, and Social Security number.

Identification Documentation: Along with the application form, individuals are usually required to provide specific identification documents to prove their identity, residency, and legal presence in the country. These may include a valid passport, birth certificate, Social Security card, or other government-issued identification.

Proof of Residency: Many jurisdictions require applicants to provide proof of residency, such as a utility bill, lease agreement, or bank statement, to verify their address.

Medical Examination Form: Some jurisdictions may require a medical examination to ensure that the applicant meets the necessary physical and mental requirements for safe driving. A medical professional typically completes this form.

Driver's Education Completion Form: For first-time drivers, completion of a driver's education program may be required. A form or certificate indicating successful completion is often necessary to apply for a driver's license.

Vision Test Form: A vision test is commonly conducted during the driver's license application process. An eye care professional or authorized personnel will assess the applicant's visual acuity and complete the required form.

These forms are typically available at the local Department of Motor Vehicles (DMV) or equivalent government agency responsible for driver licensing. It's important to check the specific requirements and forms applicable to your jurisdiction, as they can vary.

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