I understand that I may withdraw my application for an exemption at any time and that I may revoke this authorization in writing at any time prior to the FMCSA publishing a notice in the Federal Register soliciting public comments on my exemption application. I understand that I may refuse to sign this authorization and that my refusal to sign may affect my ability to obtain an exemption with the FMCSA. Please note this document has two pages, you are required to read and complete information on both documents, the last page will require your complete signature first/last name and date.ĭescription of the exemption being sought and the medical information to be released to FMCSA in support of the exemption application, including the healthcare professionals responsible for providing the records that will be released. This information may also be shared with (please check one of the following): Please check and initial the statement that applies: I do I do not authorize this information to be released. I understand that the American Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides certain protections against the release of my personal medical records and information and hereby waive all protections provided by HIPAA with regard to medical records and information related to my application for an exemption from certain requirements under 49 CFR 391.41. I understand that the medical records and information that will be disclosed by the Agency may include specific health information related to the medical conditions or illnesses, injuries, diagnosis, prognosis and medical treatment provided to me which have resulted in my not being able to obtain a medical certificate to operate commercial motor vehicles in interstate commerce. I (NAME OF APPLICANT) authorize the Federal Motor Carrier SafetyĪdministration (“FMCSA” or “the Agency”) to disclose, in a public docket accessible to all interested parties via the Internet, medical records and information related to my application for an exemption from one or more of the physical qualifications standards under 49 CFR 391.41. (Signed original will be placed in the applicant’s record and a copy provided to the applicant) Protected Health Information: Any information that can be linked back to the individual applicant, can be in any form: written, electronic, or verbal. This form provides authorization to the Federal Motor Carrier Safety Administration to publish hearing or seizure exemption information in a public docket.įederal Motor Carrier Safety Administration
Flmcsr medical file driver qualification hippa update#
Update My USDOT Number and/or Authority.Apply for a New USDOT Number and/or Authority.ADA Requirements for Over-the-Road Bus Companies.
National Registry of Certified Medical Examiners.
Regulations Regulations, Rules, & Notices.Billing an insurance company for this visit is health insurance fraud.įMCSA (Federal Motor Carrier Safety Administration) regulations have made it more difficult to get CDL Card or renew your CDL license. Call your health plan provider if you have questions. If your employer requires a Urine Drug Screen, please see our front desk staff for more information.īig Apple Urgent Care cannot use your health insurance plan for this federal administrative visit because a CDL Medical Exam by a DOT Medical Examiner is NOT covered under any health plan. We are available to provide CDL medical exams 7 days a week and walk-ins are welcome!Īs of May 21, 2014, only US DOT certified federal medical examiners can give you a CDL card.īig Apple Urgent Care does not administer drug testing for issuing a Medical Examiner’s Certificate. Our providers are FMCSA National Registry Certified Medical Examiners, and are qualified to perform CDL/DOT/TLC physicals.
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