Form VS-113 Vermont

Medical Evaluation Report

To be completed by a licensed physician when applying for a permanent disabled parking placard, disabled plates, and/or when a medical form is requested by the department to be submitted to the Department of Motor Vehicles.

Universal Medical Evaluation form for Vermont Department of Motor Vehicles, - To be completed based on reason for application: license, permit, School Bus Endorsement (Type II), Department Request or new/update medical condition, - Section A: patient's name, mailing address, physical address, gender, date of birth, social security number, VT driver license/ID number and certify truthfulness, - Section B: medical history with conditions like seizures, cancer, spinal injury, hypertension, diabetes, COPD, arthritis, degenerative joint disease, psychiatric disorder, amputation and its permanence or condition, - Section C: disability type for disabled parking plates, - Section D: medical examiner's opinion regarding patient's fitness to drive, - Section E: medical examiner's certificate signed by a licensed physician, physician assistant or nurse practitioner