Commercial Driver Diabetes Medical Waiver Form
Request form for commercial drivers with insulin-treated diabetes seeking a medical waiver. Please complete all fields accurately to support your waiver evaluation.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Primary Care Provider Name
*
Primary Care Provider Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently using insulin to treat diabetes?
*
Yes
No
Date of most recent severe hypoglycemic event (if any)
-
Month
-
Day
Year
Date
Describe your current diabetes management plan (medications, monitoring, recent A1C if known)
*
Signature
*
Submit Waiver Request
Submit Waiver Request
Should be Empty: