PennDOT DL-104 DS Psychiatric Form | Electronic Submission

What Is PennDOT Form DL-104 DS?

Form DL-104 is the General Psychiatric Form used by licensed healthcare professionals in Pennsylvania to evaluate and report a patient’s psychiatric condition as it relates to driving safety. The “DS” suffix indicates the version designed for electronic submission through a secure digital process (typically DocuSign).

According to official PennDOT documentation, this form is intended exclusively for healthcare professionals. Access to the actual fillable form requires login credentials issued by PennDOT’s medical reporting system. The publicly available DL-104 DS PDF provides instructions for completing and submitting the form online.

You can download the official electronic submission instructions here: Download PennDOT Form DL-104 DS (PDF).

Purpose of the General Psychiatric Form

Pennsylvania law requires healthcare providers to report certain medical conditions that could impair a driver’s ability to operate a vehicle safely. Under Pennsylvania Code Title 67, Chapter 83, providers must report mental disorders that may manifest as:

• Inattentiveness to the task of driving (for example, due to preoccupation, hallucination, or delusion)
• Contemplation of suicide, as may be present in acute or chronic depression or other disorders
• Excessive aggressiveness or disregard for the safety of self or others, presenting a clear and present danger

The DL-104 form allows providers to document diagnoses, treatments, medications, hospitalizations, and their professional opinion on whether the patient is qualified to drive. PennDOT’s Medical Advisory Board uses this information to make licensing decisions, which may include restrictions, recall of driving privileges, requests for additional evaluations, or no action.

Who Needs to Complete Form DL-104 DS?

This form is completed by qualified healthcare professionals—not by the driver. Providers who may use it include physicians, psychiatrists, psychologists, and other authorized practitioners who diagnose or treat mental health conditions.

Drivers may be required to undergo a psychiatric evaluation (and have this form submitted) in situations such as:

• When applying for or renewing a Pennsylvania driver’s license and a psychiatric condition is disclosed or identified
• Following a report of a mental health condition that could affect driving safety
• As part of a medical review process initiated by PennDOT after an initial report (often using Form DL-13)
• When a treating provider determines the patient’s condition warrants formal reporting under state regulations

Note: There is a related form (DL-104A) specifically for school bus drivers. The standard DL-104 applies to non-school-bus drivers under Chapter 83 regulations.

How Electronic Submission Works (DL-104 DS)

In 2023, PennDOT expanded electronic submission options for many medical and driver licensing forms, including the DL-104. Forms marked with the “DS” suffix support secure online completion and digital signatures.

According to the official DL-104 DS instructions:

1. Healthcare providers must first obtain medical reporting login credentials from PennDOT if they do not already have them. Request credentials through the official medical reporting portal.
2. Access the electronic form via the secure link provided in the DL-104 DS instructions document.
3. Enter your full name and email address (and any additional signer information if required).
4. Click “Begin Signing” to open the form in the DocuSign platform.
5. Complete all required fields regarding the patient’s psychiatric history, current condition, treatments, and your professional assessment of driving fitness.
6. Add your electronic signature when prompted.
7. Select “Finish.” The completed form is automatically emailed to PennDOT for processing.

For technical issues with the digital signature process, contact PennDOT’s Driver and Vehicle Services Customer Call Center at 717-412-5300 and reference “DocuSign DVS.” For questions about the form content itself, reference “Driver Licensing Form” or email [email protected].

Official medical reporting forms page: PennDOT Medical Reporting Forms.

Key Sections Typically Included on the Form

While the exact fillable form is restricted to credentialed providers, publicly available descriptions and related medical forms indicate that the DL-104 generally collects:

• Patient identification details (name, date of birth, driver’s license number, address, contact information)
• Length of time the provider has treated the patient
• Diagnoses of mental or emotional disorders
• Details of significant impairments that may affect attentiveness or safe driving
• Information on hospitalizations, treatments, medications, and counseling
• Provider’s professional opinion regarding the patient’s fitness to drive
• Signatures of the healthcare provider (and patient attestation where applicable)

Accuracy and completeness are essential. Incomplete or inaccurate information can delay processing or lead to incorrect licensing decisions.

Medical Criteria and Legal Basis

PennDOT’s Medical Advisory Board establishes the physical and mental criteria for driver licensing. Mental criteria relevant to psychiatric reporting include cognitive impairments and the specific symptoms listed earlier under § 83.5(b)(5).

Healthcare providers are legally required under Section 1518(b) of the Pennsylvania Vehicle Code to report, within 10 days, any patient over 15 years of age diagnosed with a condition that could impair driving ability. Reports can be made via letter, the Initial Reporting Form (DL-13), or condition-specific forms such as DL-104.

More details on medical criteria are available on the official page: PennDOT Medical Criteria.

What Happens After Submission?

Once PennDOT receives the completed DL-104 DS form, the information enters the medical review process. Possible outcomes include:

• No change to the driver’s license status
• Addition or removal of restrictions
• Request for additional medical information or a driving examination
• Recall (suspension) of driving privileges if the condition is deemed disqualifying
• Restoration of privileges once medical clearance is established

Drivers and providers can contact the Medical Unit at 717-787-9664 or [email protected] for status inquiries (hours typically 8 a.m. – 4:15 p.m., Monday–Friday).

How to Request Healthcare Provider Credentials?

Only credentialed healthcare personnel can access the protected medical reporting forms. To request credentials:

1. Visit the official Medical Reporting Forms page.
2. Use the “Request health care personnel credentials” button or link.
3. Complete the required registration information.

Direct link for credential requests is available on: https://www.pa.gov/agencies/dmv/resources/medical-reporting/medical-reporting-forms.

Additional Resources and Contact Information

• Medical Reporting Overview: PennDOT Medical Reporting Center
• Medical Reporting FAQs: Frequently Asked Questions
• Customer Call Center: 717-412-5300
• Medical Unit Phone: 717-787-9664
• Email: [email protected]
• Mailing Address: Bureau of Driver Licensing, P.O. Box 68682, Harrisburg, PA 17106-8682

Download the Official DL-104 DS Instructions

For the most current electronic submission instructions and access process, always use the official Commonwealth of Pennsylvania document:

Download Pennsylvania PennDOT Form DL-104 DS – General Psychiatric Form (Electronic Submission PDF)

This form plays an important role in balancing individual mobility with public roadway safety. Healthcare providers are encouraged to stay current with PennDOT’s medical reporting requirements to ensure accurate and timely submissions.