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Jjkeller. com Printed in the United States 651-FS-L2 MEDICAL EXAMINER S CERTIFICATE I certify that I have examined in accordance with the Federal Motor Carrier Safety Regulations 49 CFR 391. SIGNATURE OF MEDICAL EXAMINER TELEPHONE MD DATE DO Physician Assistant Chiropractor Advanced Practice Nurse DRIVER S LICENSE NO. ADDRESS OF DRIVER MEDICAL CERTIFICATE EXPIRATION DATE DISTRIBUTION 1 COPY TO THE DRIVER 1 COPY TO THE MOTOR CARRIER STATE. ALL WRITTEN OR PRINTED INFORMATION MUST BE...
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What is the Medical Examiner’s Certificate?

The Medical Examiner’s Certificate is the document that enables you to use a commercial motor vehicle. It must be completed by a medical examiner who examines you and makes a decision according to the results of this medical examination. The examiner gives you the original of the certificate after its completion and keeps a copy of it for about 3 years.

What is the Medical Examiner’s Certificate for?

This document is designed to determine if you are physically qualified to drive a CMV (commercial motor vehicle). It is possible to receive this document in the form of a card. For this you must buy a special medical card from the provider of motor carrier templates before the examination so that the examiner could complete it and sign. You may also print it on cardstock paper. This way it is possible to change the size of the certificate according to your needs.

When is the Medical Examiner’s Certificate Due?

The Medical Examiner’s Certificate can remain valid for maximally two years after you receive it. When it expires, you must be examined by a medical specialist again to renew the document.

Is the Medical Examiner’s Certificate Accompanied by Other Forms?

No, the certificate is a single document that you need to be eligible to drive any CMV.

What Information do I Include in the Medical Examiner’s Certificate?

The examiner certifies in this document that the applicant was examined according to the Federal Motor Carrier Safety Regulations. The name of the applicant is indicated first. The examiner determines that you are able to drive if one of the following is applicable:

  • you wear corrective lenses or hearing aid;
  • you drive within an exempt intracity zone;
  • you can provide a Skill Performance Evaluation Certificate;
  • or you are qualified by operation of 49 CFR 391.64.

The certificate must include the information about the medical examiner: name, address, telephone number, status (chiropractor, MD, Doctor of Osteopathic Medicine, physician assistant, advanced practice nurse, etc.), license or certification number, signature. The driver’s name, address and license are also required. Additionally, the examiner must establish the expiration date and indicate it in the certificate.

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Please select a version for Fillable MCSA-5876 form
  • 2021 MCSA-5876 Fillable
  • 2018 MCSA-5876 Fillable
  • 2015 MCSA-5876 Fillable
  • More...