Clearance Notes & FMCSA Forms
If you have a medical condition that requires sign-off from a specialist before your DOT physical, download the matching template below and bring it to your treating provider in advance. Coming to your exam with the completed form can save you a return visit.
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FMCSA-Specific Forms
Official federal forms- Federal Hearing Exemption — New Application
- Federal Hearing Exemption — Renewal
- Federal Seizure Exemption — New Application
- MCSA-5870 — Insulin-Treated Diabetes Mellitus Assessment
- MCSA-5871 — Vision Evaluation Report
- MCSA-5872 — Non-Insulin-Treated Diabetes Mellitus Assessment
- MCSA-5875 — Medical Examination Report
- MCSA-5895 — Medications Form
Specialist Clearance Note Templates
Sorted A–Z by condition- AAA (Abdominal Aortic Aneurysm)
- ADD / ADHD
- Afib / Aflutter
- Angina
- Anxiety Disorders
- Aortic Regurgitation
- Aortic Stenosis
- Bipolar Disorder
- CABG (Coronary Artery Bypass Graft)
- Cardiac Pacemaker
- Cardiac Valve Replacement
- CHF (Congestive Heart Failure)
- CKD (Chronic Kidney Disease)
- COPD / Emphysema
- Depression
- Dilated Cardiomyopathy
- DVT / PE
- HCM (Hypertrophic Cardiomyopathy)
- Headache / Migraine
- Heart Transplant
- HTN (Hypertension)
- Interstitial Lung Disease
- Ménière's Disease
- Methadone Clearance Letter
- MI (Myocardial Infarction)
- Mitral Regurgitation
- Mitral Stenosis
- Multiple Sclerosis
- OSA (Obstructive Sleep Apnea)
- PAD (Peripheral Artery Disease)
- Parkinson's Disease
- PCI (Percutaneous Coronary Intervention)
- Prosthetic Heart Valve
- PVS (Pulmonic Valve Stenosis)
- Restrictive Cardiomyopathy
- Schizophrenia
- Spontaneous Pneumothorax
- Stroke / TIA
- Suboxone / Buprenorphine Clearance Letter
- SVT (Supraventricular Tachycardia)
- Syncope
- TAA (Thoracic Aortic Aneurysm)
- TBI / Concussion
Templates are provided as fillable PDFs intended for the driver's treating specialist. Always verify the form meets current FMCSA requirements before issuing a medical certificate.