How to Fill Out and Submit the Utah DLD-134 Medical Report Form

The Utah DLD-134 medical report form is a one-page Functional Ability Evaluation that a licensed healthcare professional fills out to confirm you can safely drive despite a medical condition. You sign the top, your provider completes the clinical assessment on the bottom, and the finished form goes to the Driver License Division (DLD) — preferably through the online Medical Portal at dld.utah.gov/medical-portal/, or by fax to 801-957-8698 or email to dlmedical@utah.gov.¹ The DLD uses your provider’s assessment to decide whether to issue, restrict, or deny your driving privileges.

When You’ll Be Asked for a DLD-134

Utah law puts the reporting duty on you. Under Utah Admin. Code R708-7-4, every license applicant or holder has to answer health questions at each application, stop driving when unsure about an impairment, get a medical evaluation, and report the condition to the Division promptly.² Short-term illnesses lasting fewer than three months do not need to be reported, as long as you stay off the road until you recover.³

The Division can also learn about a condition another way. A law enforcement officer may flag a concern after a stop or crash. A Utah healthcare provider is allowed to notify the DLD directly and has liability immunity for doing so. And the health questionnaire you answer at renewal can trigger a request.

Conditions that commonly lead to a DLD-134 request include epilepsy and other seizure disorders, cardiovascular disease, diabetes, neurological conditions, pulmonary disease, sleep disorders, and mental health conditions.

Where to Get the Form

The DLD-134 is a free PDF on the Driver License Division website at dld.utah.gov, under the medical standards or healthcare professionals pages.⁴ You can also pick one up at any DLD office. The form references a companion document, “Functional Ability in Driving: Guidelines and Standards for Health Care Professionals,” which contains the tables your provider uses to assign an assessment level. Providers can download it from dld.utah.gov/healthcare-providers/.⁵

Your Part of the Form

Your section is short. The top of the DLD-134 asks for your name, date of birth, driver license number, signature, and the date. That’s it. There is no health history section for the driver to complete.⁵ Fill in those fields, sign, and hand the form to your provider.

You cannot assign yourself a safety assessment level. That’s the provider’s call.

What the Healthcare Professional Fills In

The bottom of the form is where the medical judgment happens. Your provider reviews your condition and assigns a numbered safety assessment level for each relevant category. The form lists ten:⁵

Category A: Diabetes and metabolic conditions
Category B: Cardiovascular
Category C: Pulmonary
Category D: Neurologic
Category E: Seizures and episodic conditions
Category F: Learning, memory, and communication disorders
Category G: Mental health
Category H: Alcohol and other drugs
Category J: Musculoskeletal or chronic debility
Category K: Alertness or sleep disorders

The Medical Advisory Board’s guidelines define eight levels. Level 8 means no driving.³ Your provider picks the level that matches the severity and stability of your condition and, in some cases, sets the schedule for the next evaluation.

The form also lets the provider recommend specific restrictions. The printed options are a speed limit of 40 mph or less, area restrictions requiring a driving review, supplemental oxygen while driving, and daylight driving only.⁵ The provider prints their name, degree, and license number, then signs.

Who Is Allowed to Sign

Physicians and surgeons licensed to practice medicine can complete the DLD-134 at any assessment level. Nurse practitioners and physician assistants can also evaluate and sign at all levels, on two conditions: they must be adequately trained and qualified in the specific category being evaluated, and they must defer to another provider when they lack the expertise.³ A healthcare professional cannot complete the form for themselves.

Avoiding a Rejected Form

The most common reason a DLD-134 gets kicked back is a missing assessment level. Your provider needs to check at least one category and write in a specific level number; a blank assessment gives the Division nothing to act on. Confirm the provider signed and included their license number. The form itself notes that medical information should be limited to what’s needed for safe driving, so there is no need for a long narrative — the level and any restrictions are what matter.

Submitting the Completed Form

Once the form is finished, there are three ways to get it to the Division:

Online through the Medical Portal at dld.utah.gov/medical-portal/ (preferred)
Fax to 801-957-8698
Email to dlmedical@utah.gov¹

Many clinics submit the form for the patient through the portal. Ask your provider’s office whether they’ll send it, so it doesn’t sit on a counter waiting for someone to act.

What Happens After You Submit

Division staff compare the assessment level your provider assigned to the published guidelines and decide whether to issue your license unrestricted, issue it with restrictions, or deny it. For complex or borderline files, the Division may convene a panel of the Driver License Medical Advisory Board to review the evidence and recommend an outcome.⁶ The Division may also request additional tests or a specialist consult before deciding. You’ll get written notification of the outcome and any follow-up schedule.

If restrictions are imposed, they appear as coded entries on your license. Common ones tied to medical evaluations include:

Code B: Corrective lenses required
Code C: Mechanical aid or compensatory device in the vehicle
Code D: Prosthetic aid required
Code G: Daylight driving only
Code 6: Roads with a posted speed limit of 40 mph or less
Code 7: Automatic transmission only

Seizure-Free Waiting Periods

Seizure disorders have their own rules under Category E. After any seizure, your provider should assign Level 8, meaning no driving. You become eligible for a license — possibly with restrictions — after at least three months seizure-free, provided your healthcare professional expects that to continue.⁷

Narrow exceptions exist. A Medical Advisory Board panel may shorten the interval in certain cases, such as a seizure caused by a medication known to provoke one. Seizures that consistently happen only during sleep, or simple partial seizures that never impair consciousness, may be exempt from the restriction — but only after the pattern has been documented for at least twelve months.

Intrastate commercial drivers wait longer: at least six months seizure-free before an intrastate waiver application will be considered.⁷

Appealing a Denial or Restriction

If the Division suspends, revokes, restricts, or denies your license based on a medical evaluation without first convening a Medical Advisory Board panel, you have ten days from the date you receive notice to request a panel review. The panel reviews the evidence, issues written findings and conclusions, and the Division then affirms or modifies the earlier decision.⁸ Division and Board actions are subject to judicial review beyond that.⁶

Ten days is tight. If you think the decision rested on incomplete information, use the window to gather updated records and a revised DLD-134 from your provider before requesting the panel. The panel weighs medical evidence, so a stronger file matters more than procedural arguments.

Vision Problems Use a Different Form

Vision issues are handled on the Certificate of Visual Examination, not the DLD-134. The two can overlap in practice, especially for diabetes or neurological conditions that affect eyesight. For a regular Utah license, you need at least 20/40 visual acuity and 90 degrees of peripheral vision in at least one eye.⁹ If you fail the eye screening at a DLD office, your eye care professional will need to complete the Certificate in addition to any DLD-134 your physician submits.

Commercial Drivers Have a Separate Federal Layer

If you hold a CDL, the DLD-134 covers the state medical evaluation, but federal requirements are separate. CDL holders operating vehicles over 10,000 pounds in interstate commerce must carry a valid Medical Examiner’s Certificate issued by an FMCSA-registered examiner.¹⁰ You also self-certify your operating category with the DLD and provide a copy of the federal certificate. Letting the certificate lapse downgrades your commercial driving privileges.

For intrastate commercial drivers with conditions that would disqualify them federally, Utah’s Medical Advisory Board can issue a state-level waiver under Utah Code 53-3-303.5, as long as the waiver does not trigger federal sanctions against the state.⁶ The applicant pays the administrative costs of the waiver on top of standard license fees.

1
Utah Driver License Division. Health Care Professionals
2
Legal Information Institute. Utah Admin Code R708-7-4 – Drivers Responsibilities
3
Utah Driver License Division. Medical Guidelines and Standards
4
Utah Driver License Division. Medical Standards for Drivers
5
Utah Driver License Division. Functional Ability Evaluation Medical Report
6
Utah Legislature. Utah Code 53-3-303.5 – Driver License Medical Advisory Board – Medical Waivers
7
Utah Legislature. Functional Ability in Driving – Guidelines and Standards for Health Care Professionals
8
Utah Legislature. Utah Code 53-3-303 – Driver License Medical Advisory Board – Membership
9
Utah Driver License Division. Vision Requirements for Drivers
10
Federal Motor Carrier Safety Administration. Medical