Long Form Request

Long Form Request

To request copies of the DOT Long Form.
Who is making this request? *

Patient Employer
Name of person making request:

First Name Last Name
Full Legal Name of Patient *

First Name Last Name
D.O.B. *

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Last 4 digits of Drivers License *
Requests can be processed via Fax or Email, please fill out the respective box.
Recipients Email
Recipients Fax

Area Code Phone Number
Patient Authorization

I am personally authorizing the release of my own drivers examination health report. I understand that this information can either be sent via fax or email.
Employer Authorization

I have a signed release on file authorizing this request from the employee listed above. Failure to do so would be a breach of HIPPA. This report can either be sent via fax or email.
Signature of Requesting Party *

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If you do not see a confirmation page, your request was not processed. Please try again, or send us an email.
Should be Empty: