OAR 735-074-0120. The Mandatory Report to DMV

(1) To report a severe and uncontrollable functional or cognitive impairment as required by OAR 735-074-0110, the reporting physician or health care provider must complete and submit to DMV a Mandatory Impairment Referral form (DMV form 735-7230). A report may also be submitted by proxy on a form approved by DMV and substantially similar to DMV Form 735-7230 containing all required content, including the statement “Proxy for DMV’s Mandatory Impairment Referral form (DMV form 735-7230).” (2) To report visual acuity or field of vision not meeting DMV standards as required by OAR 735-074-0100, the reporting physician or health care provider must complete and submit to DMV a Mandatory Impairment Referral form (DMV form 7230). A report may also be submitted by proxy on a form approved by DMV and substantially similar to DMV Form 735-7230 containing all required content, including the statement “Proxy for DMV’s Mandatory Impairment Referral form (DMV form 735-7230).” (3) A form described in section (2) of this rule must contain the following information: (a) The name, address, date of birth, sex, and Oregon driver license or identification card number (if known) of the person being reported; (b) The functional or cognitive impairment(s) being reported, as described in OAR 735-074-0100 or 735-074-0110; (c) A description of how the person reported is affected by the impairment; (d) The name, professional license or certification number and signature of the reporting physician or health care provider; and (e) The date of the person's most recent examination, within the prior six months of the date the form is submitted to DMV. (4) If available, and applicable, the following information may be included on the form: (a) Any underlying medical diagnosis or condition related to the reported impairments; (b) The date of the person's last episode of loss of consciousness or control, date of cerebrovascular accident (CVA), cardiac event or intoxicant use or relapse; (c) Medication prescribed that may interfere with safe driving behaviors or medication prescribed to treat the impairment(s) reported; and (d) The address and phone number, of the reporting physician or health care provider.